[Chaotic atrial tachycardia-induced cardiomyopathy: report of an isolated case]

Chaotic atrial tachycardia is a rare arrhythmia that has no known etiology and that usually inflicts upon newborn infants. The diagnosis is established using the surface electrocardiogram (ECG) which shows a spectacular polymorphism and irregularity of the atrial electrical activity. Clinical tolerability is variable depending on the ventricular rhythm. Cases that are not well tolerated and cases who do not recover spontaneously require medical treatment which relies mainly on amiodarone and other class IC anti-arrhythmic drugs. There is usually complete recovery during the first few months of life. The authors present the case of a female patient who was diagnosed with chaotic atrial tachycardia with induced cardiomyopathy following birth. She was successfully treated with amiodarone but had several relapses of the arrhythmia upon discontinuation of the drug. Although this observation is classic in its presentation, we consider that it is useful to remember this rare and frequently forgotten syndrome and to report the unique and particular aspects of our case and its evolution.

[Early complications of stenting in children and young adults with congenital heart disease]

We report the early complications of stent implantation. Since 1/1/97 to 1/12/02, we implanted 91 stents in 76 patients. Median age and weight were 15 years (range 0.3-43) and 49 kg (range 3-96). Primary diagnosis were: pulmonary atresia with ventricular septal defect (n = 17), tetralogy of Fallot (n = 13), aortic coarctation (n = 15), transposition of the great arteries (n = 3), truncus arteriosus (n = 6), univentricular heart (n = 7), other anomalies (n = 28). Indications to stent implantation were: stenosis of the pulmonary outflow and/or pulmonary branches (n = 44), aortic recoarctation (n = 14), native aortic coarctation (n = 1), systemic venous channels obstruction (n = 14), other (n = 3). The stents were: Palmaz (n = 57), non premounted CP (n = 8), premounted CP (n = 3), Palmaz Corinthian (n = 19), self-expanding (n = 4). Procedural complications occurred in 24 patients (31%) and included: 11 balloon bursting, 8 stent slipping, 1 stent migration, 4 wall dissections. Five patients (21%) needed urgent surgery. Sixty three percent of complications occurred during pulmonary outflow or pulmonary branches stenting, 25% during stenting of the aortic arch, 12% during other procedures. All but 2 complications were observed with non premounted stents. In conclusion, the use of not premounted stents, although widely diffuse, has a not negligible incidence of complications, leading to longer procedures, to the use of a large variety of materials and needing more than occasionally a surgical solution. A larger use of premounted stents, when possible, is recommended.

[Experience of implantation of prefitted Palmaz Corinthian stents]

We report our recent experience with the Palmaz Corinthian stent in children. Since 1/10/01 to 1/11/02 we implanted 18 Palmaz Corinthian stents in 12 children. Median age and weight of patients were 5.6 years (range 0.25-13) and 17.9 kg (range 3-36), respectively. Primary diagnosis were: pulmonary atresia with ventricular septal defect (n = 7), complex transposition of the great arteries (n = 2) and others (n = 3). Indications to stent implantation were: pulmonary branches stenosis (n = 9), stenosis of the ductus arteriosus (n = 1), stenosis of systemic veins (n = 2). All stents were pre-mounted and co-axially advanced over a standard guidewire across the stenotic site, using a 6F short introducer. Stent deployment was performed by hand inflation of the balloon. Final angiography confirmed correct positioning and ruled out complications. Median fluoroscopy time was 18 minutes (range 12-56). All stents reached their nominal diameter; 2 were post-dilated to 125 and 150%. No procedural complications occurred. Despite the impossibility of distal injection, stent positioning was always correct. In conclusion, due to the availability of pre-mounted stents, and the need of short 6F sheaths, the use of the Palmaz Corinthian stent in children is relatively simple. Primary results are generally good in terms of adequate delivery and absence of complications. However, the impossibility of distal injection makes more difficult the choice of the deployment site. Due to the limited possibility of over-dilation, the use of this stent has to be limited to the stenosis of peripheral pulmonary branches or to lesions that can be surgically treated during further surgical procedures.

[Percutaneous closure of an interatrial communication via the internal jugular route using an Amplatzer prosthesis]

Closure of interatrial communications by interventional catheterisation is recommended and effective. The usual approach is via the femoral vein. However, difficulty in positioning the probe and the guide in a stable fashion across the septal defect occurred during closure of the interatrial communication by the percutaneous route in a 71 year old female with severe scoliosis. This deformity most certainly contributed to the failure of the femoral approach. The decision for closure by the internal jugular route was taken and allowed closure of the interatrial communication to be achieved. The internal jugular route can be an alternative for closure of interatrial communications with difficult access.

Assessment of muscular ventricular septal defect closure by transcatheter or surgical approach: a three-dimensional echocardiographic study

AIMS

Previous classification of muscular ventricular septal defects (VSDs) visualized on two-dimensional echocardiography relied on artificial divisions of the septum. New visualization of the ventricular septum integrating the third dimension would facilitate communication between cardiologists and surgeons. The objectives of this study were (1) to assess in patients with muscular ventricular septal defects the accuracy of left ventricular three-dimensional echocardiographic reconstructions in demonstrating the position, the size and the tissue rims of the defects; (2) to compare findings by three-dimensional echocardiography with those obtained by surgical and transcatheter approaches.

METHODS AND RESULTS

Twenty-six patients, aged from one month to 40 years, with muscular ventricular septal defects underwent three-dimensional echocardiographic study. From the left ventricular three-dimensional echocardiographic reconstructions, the localization, the maximal diameter and the tissue rim of the defect were analysed and compared with surgical or transcatheter findings. Optimal three-dimensional echocardiographic reconstructions were obtained in 22 patients. Nineteen had a single muscular ventricular septal defect and three had multiple muscular ventricular septal defects. The muscular ventricular septal defect localizations were the inlet septum in three, the outlet septum in three, the mid-muscular septum in 14 and the apex in eighth. In 10 patients who underwent surgical closure, the correlation between three-dimensional echocardiography and surgery for muscular ventricular septal defect maximal diameter was y=0 x 95 x +0.13 (r=0.98; P<0.001). The agreement between three-dimensional echocardiographic and intraoperative findings on muscular ventricular septal defect localization were complete. In five patients who underwent transcatheter closure, the mean difference between three-dimensional echocardiographic maximal diameter and stretched diameter was 1 x 8+/-0 x 5 mm.

CONCLUSION

The three-dimensional echocardiographic left ventricular views provide a new and easily communicated visualization of various muscular ventricular septal defects. Such new imaging should contribute to the surgical and transcatheter treatments of muscular ventricular septal defects.

[Marfan syndrome in the newborn and infants less than 4 months: a series of 9 patients]

We report a series of 9 children with neonatal Marfan syndrome. The diagnosis was made on a striking facial dysmorphia associated with arachnodactyly type skeletal anomalies. They all had cardiovascular anomalies: aortic dilatation 9 times, and mitral and/or tricuspid valve prolapse 8 times. Three children underwent ascending aorta replacement with the Yacoub technique. There was one operative death in a young infant and the two survivors required further surgery for gross mitral insufficiency and an aneurysm of the horizontal aorta. Three children died before the age of 1 year from cardiac insufficiency linked to massive leaks of all the valves. The three youngest children in the series did not undergo any procedure and were followed up for a slowly growing dilatation of the initial aorta. The prognosis of neonatal Marfan syndrome is weighted with a heavy mortality. The timing of surgical intervention in case of excessive dilatation of the aortic root is difficult to determine. It depends not only on the aortic diameter but also on the aortic valve function and the existence of other mitral or tricuspid lesions. Surgical treatment for lesions of the initial aorta and the atrioventricular valves improves the short-term prognosis but the risk of re-intervention is higher.

[Percutaneous closure of a paravalvular mitral regurgitation with Amplatzer and coil prostheses]

The authors report a case of percutaneous closure of paravalvular mitral regurgitation in a 9 year old child. This patient had complete atrioventricular canal with levo-isomerism completely repaired with replacement of the left atrioventricular valve by a mechanical prosthesis. One year after an episode of infectious endocarditis, the patient was readmitted because of jaundice due to haemolysis attributed to paravalvular mitral regurgitation. Transoesophageal echocardiography demonstrated a crescent-shaped dehiscence of the prosthesis opposite the left atrial appendage associated with a small paraseptal regurgitation. First of all, a 6 mm Amplatzer Septal Occluder and a 5 x 5 coil were introduced by retrograde catheterisation to treat the regurgitation due to the valve dehiscence. This procedure was completed 3 months later by the implantation of a second 8 mm Amplatzer prosthesis for persistent haemolysis. Closure of the paraseptal regurgitation resulted in a reduction of the patient's transfusional requirements.

[3D-transthoracic echocardiography: a selection method prior to percutaneous closure of atrial septal defects]

Prior to putting in place a percutaneous device, the assessment of the atrial septal defect anatomy is mandatory. The 3D transthoracic echocardiography is a non-invasive method bringing an imaging of the septal defect surface and its borders. Fifty-two patients ageing from 3 to 16 years old had a rotational 3D transthoracic echocardiography. Thirty-six (69%) were selected for a percutaneous closure (borders > 7 mm and a septal surface/atrial septal defect ratio > 2). Thirty-two of these selected patients (89%) benefited from the Amplatz prosthesis implantation with success. The maximal 3D diameter of the septal defect was 20 + 4 mm (14-30) compared to the mean size of prosthesis at 22 mm (18-30). Four of the 36 patients (aneurismal septum or a borderline septal surface/atrial septal defect ratio) were secondarily oriented to surgeons. Sixteen patients (31%) were selected directly to a surgical closure. The lack of borders or septal surface were confirmed by the surgical view. The 3D transthoracic echocardiography allows to define new criteria for the selection of patients prior to a percutaneous closure of atrial septal defects. This prospective study demonstrates that 9 out of 10 patients who had the 3D criteria had a percutaneous closure of the septal defect.

[Atrial septal defect calibration: comparison of methods using balloons and 3D-transesophageal echocardiography]

The atrial septal defects (ASDs) occlusion by cardiac catheterization is an alternative to the surgical technique. The use of stretching by balloon is considered as the gold-standard for the ASDs calibration. Three dimensional transesophageral echocardiography (3D-TEE) brings an imaging of the ASD surface and allows the measurement of its maximal diameter. With the goal of a percutaneous ASD occlusion, seventy patients had a simultaneous calibration of the ASDs by 3D-TEE and the balloon method. The mean maximal diameter measured by 3D-TEE was at 20 + 15 mm (range 10-28 mm) compared to the mean balloon-stretched diameter at 22 + 5 mm (range 9-31 mm). The correlation between both methods is good (y = 3.15 + 0.77x, r = 0.8, p < 0.0001). The mean difference between the diameters measured by both methods was 1.85 + 3.17 mm. The ASD visualized by 3D-TEE was single in 54 cases and multiple in 16 cases. The correlation between both methods was excellent in those with a single ASD (y = 1.74 + 0.84x; r = 0.85. p < 0.0001) but it was poor in those with multiple ASD (y = 12.4 + 0.4x; r = 0.45). The calibration by the balloon method which tests the septum resistance is an additive method to 3D-TEE which measures the anatomic diameter of ASD.

Combined cerebral and lower-limb revascularization

Brachiocephalic atherosclerosis and aortoiliac occlusive disease are often encountered concomitantly, The authors report a technique of combined brachiocephalic and femoral revascularization in which a single transthoracic approach is used.