Predictors of prolonged pleural effusion after Fontan operation

Prolonged pleural effusion is a fairly common condition which has considerable impact on complicated and longer hospital stays after Fontan surgery. Identifying the patient population prone to have pleural effusions is still seeking for an answer. This study is to determine the variables that may predict prolonged pleural effusion according to the data of 69 patients who underwent Fontan operation between June 2018 and December 2020 and survived to date. Prolonged pleural effusion was defined as the need for a chest tube for more than 7 days. Two patient groups, with and without prolonged effusion, were compared in terms of pre-, peri-, and post-operative variables. The patients were subdivided into "high-risk" and "low-risk" groups based on the pre-operative catheterisation data. The most frequent main diagnosis was tricuspid atresia (n: 13, 19%). Among 69 patients, 28 (40%) had prolonged pleural effusion whereas 11 (16%) had effusions that lasted longer than 14 days. Ten patients among prolonged effusion group (35%) had pulmonary atresia coexistent with the main diagnosis. Fontan operation was performed in 6 patients (8.7%) over the age of 10, and 4 of these patients (67%) had prolonged pleural effusion. Among numerous variables, statistical significance between the two groups was achieved in pre-operative mean pulmonary artery pressure, post-operative albumin, C-reactive protein levels, length of hospital stay, duration of chest tube drainage, and amount of effusion per day. Early recognition and treatment strategies with routine medical protocol use remain to be the cornerstone for the management of post-operative prolonged pleural effusions after Fontan surgery.

Effects of Systolic Dysfunction on Clinical and Diagnostic Parameters in Pediatric Patients with Isolated Left Ventricular Non-compaction

OBJECTIVE

Left ventricular non-compaction is a rare cardiomyopathy following an early arrest in endomyocardial morphogenesis. This study aimed to present the clinical and electrocardiographic characteristics, diagnostic features, treatment strategies, effects of systolic dysfunction on clinical and diagnostic parameters, and follow-up of pediatric patients diagnosed with left ventricular non-compaction.

METHODS

We retrospectively reviewed children with isolated left ventricular non-compaction at Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital from January 2010 to June 2020.

RESULTS

Fifty-five children were diagnosed with left ventricular non-compaction. Thirty-two patients (58.2%) were male, and the median age of presentation was 8.5 years (1 month-17.9 years). The median follow-up of the study was 19 months (1-121 months). Fourteen (25.5%) presented with systolic dysfunction (ejection fraction < 45%), and 2 presented with resuscitated/aborted cardiac arrest. Electrocardiographic abnormalities were present in 78.2%. Fragmented QRS was observed in 6 patients, and QTc duration was 450 milliseconds and above in 17 patients (30.9%). Electrocardiographic abnormalities, low QRS voltage, fragmented QRS, and thrombus were common in patients with ejection fraction < 45% group. Atrial and ventricular arrhythmias (including ventricular fibrillation-VF) were found with similar frequency in both ejection fraction < 45% and ≥45% groups. One patient with a complete atrioventricular block and 1 with long QT syndrome and severe bradycardia underwent permanent pacemaker implantation. Five (9.1%) patients died.

CONCLUSIONS

Left ventricular non-compaction has heterogeneous clinical findings in childhood. It is essential to follow-up with the patients closely for the development of ventricular dysfunction or arrhythmias due to the progressive course of the disease. Further studies are needed since life-threatening ventricular arrhythmias can be seen, even in patients with preserved ejection fraction.

High-density Mapping Catheter (Advisor™ HD Grid) Usage for Intra-atrial Reentrant Tachycardia Ablation in Children and Young Adult Patients with Congenital Heart Disease

BACKGROUND

We aimed to share our experience of intra-atrial reentrant tachycardia mapping and ablation with a new grid-style multielectrode high-density mapping catheter (Advisor™ HD Grid) in pediatric and young adult patients with operated congenital heart disease.

METHODS

All patients with operated congenital heart disease and intra-atrial reentrant tachycardia mapping with the new grid-style catheter between October 2019 and December 2022 were included (group 1), and the results were compared to those patients who operated with conventional catheter methods before this period (group 2). All procedures were performed using the EnSite Precision 3D mapping system (Abbott Laboratories, Abbott Park, Ill, USA) with a limited fluoroscopy approach. Data were evaluated retrospectively.

RESULTS

In group 1 (n = 16; 9 male), the median age was 21 years (10-36), compared to 19 years (9-27) in group 2 (n = 10; 5 male). While irrigated radiofrequency ablation was pre-ferred in all patients, the median number of 15 lesions (8-38) in group 1 was significantly less than the median of 30 lesions (8-71) in group 2 (P =.027). The median procedure duration of 159 minutes (110-233) in group 1 was significantly shorter compared to 280 minutes (180-370) in group 2 (P <.05). Acute procedural success was achieved in all patients (16/16; 100%) in group 1 compared to 8/10 patients (80%) in group 2. During the median follow-up of 27 months (11-36), there was only 1 intra-atrial reentrant tachycardia recurrence in group 1 (1/16; 6.2%) and 2 recurrences (2/8; 25%) in group 2 during the median follow-up of 110 months (56-151). No complications related to the mapping catheter itself occurred.

CONCLUSION

In the intra-atrial reentrant tachycardia ablation of children with congenital heart disease to increase procedural success and shorten the mapping duration, the utility of Advisor™ HD Grid mapping catheter seems to be a feasible alternative.

Clinical Course and Electrophysiological Characteristics of Permanent Junctional Reciprocating Tachycardia in Children

BACKGROUND

In this study, we aimed to evaluate the clinical aspects, electrophysiological studies, and ablation results of permanent junctional reciprocating tachycardia in children.

METHODS

The study comprised 29 pediatric patients diagnosed with permanent junctional reciprocating tachycardia between 2011 and 2021 in 2 pediatric electrophysiology centers. From the file records, the basic demographic characteristics of the patients, as well as electrocardiographic and echocardiographic findings, were acquired retrospectively. The medical treatment and responses of the patients throughout follow-up, as well as the electrophysiological study and ablation data of the patients who had electrophysiological study, were assessed.

RESULTS

The mean age at diagnosis of the patients was 3.13 ± 4.43 (0-18) years and the mean weight was 18.22 ± 19.68 (3.8-94) kg. Eighteen patients (62.1%) were girls. Eleven patients (38%) developed tachycardia-induced cardiomyopathy. Tachycardia was incessant in 15 patients (51.7%). In total, 22 patients required 26 ablation procedures. Tachycardia-induced cardiomyopathy and multidrug-resistant tachycardia were the most prevalent indications for ablation. The right posteroseptal pathway was detected in 18 patients (81.8%). The acute procedure success rate was 100% (22/22). The recurrence rate was 18% (4/22) and 3 of them underwent successful ablation again. The overall success percentage was 95.4% (21/22). None of the patients had any complications. The mean follow-up period was 4.39 ± 3.05 years.

CONCLUSION

Although permanent junctional reciprocating tachycardia is uncommon, it is often persistent, resistant to medical treatment, and associated with a substantial risk of tachycardia-induced cardiomyopathy. Catheter ablation can be performed on these patients at any age, with minimal risk of complications and a high success rate. It is crucial to keep monitor of the patients' recurrence.

Common Supraventricular and Ventricular Arrhythmias in Children

The most common pediatric arrhythmias are tachycardias, and the most common type is supraventricular tachycardia, originating from or above the atrioventricular node and HIS bundle. Ventricular tachycardias are less common but more dangerous. Supraventricular tachycardias usually cause a narrow complex tachycardia unless there is a basal bundle branch block or rate-dependent aberration. A wide QRS tachycardia should be treated as ventricular tachycardias unless proven to be an supraventricular tachycardia with aberration. Diagnosis of both tachyarrhythmia types depends mainly on 12-lead electrocardiography. The most common supraventricular tachycardia type in newborns and infants is atrioventricular reentry tachycardia, related to manifest or concealed accessory pathways and in adolescent atrioventricular nodal reentry tachycardia, whereas focal atrial tachycardias consist of 10%-15% of supraventricular tachycardias during all ages. Supraventricular tachycardias have a low risk of morbidity, and ablation therapy is successful in most types with success rates over 90%. Ventricular tachycardias can be monomorphic or polymorphic, nonsustained or sustained, and can cause more hemodynamic instability than supraventricular tachycardias, requiring more close monitoring and urgent therapies. If hemodynamically unstable, synchronized cardioversion must be performed. Polymorphic ventricular tachycardias are very dangerous and often associated with primary ion channel defects (channelopathies), which can cause sudden cardiac death.

Mutational spectrum of congenital long QT syndrome in Turkey; identification of 12 novel mutations across KCNQ1, KCNH2, SCN5A, KCNJ2, CACNA1C, and CALM1

INTRODUCTION

Long QT syndrome (LQTS) is of great importance as it is the most common cause of sudden cardiac death in childhood. The diagnosis is made by the prolongation of the QTc interval on the electrocardiography. However, clinical heterogeneity and nondiagnostic QTc intervals may cause a delay in the diagnosis. In such cases, genetic tests such as next-generation sequencing (NGS) panel analysis enable a definitive diagnosis. We present the first study that aimed to expand the LQTS's mutational spectrum by NGS panel analysis from Turkey.

METHODS

Fifty-seven unrelated patients with clinically diagnosed LQTS were investigated using an NGS panel that includes six LQTS-related genes. Clinical aspects, outcome, and molecular analysis results were reviewed.

RESULTS

Pathogenic (53%)/likely pathogenic (23%)/variant of unknown significance (4%) variants were detected in any of the genes examined in 79% of the patients. Among all detected variants, KCNQ1(71%) was the most common gene, followed by SCN5A (11%), KCNH2 (10%), CALM1 (5%), and CACNA1C (3%). Twelve novel variants were detected. Among the variants in KCNQ1, the c.1097G>A variant was present in 42% of patients. This variant also composed 31% of the variants detected in all of the genes.

CONCLUSION

Our study expands the spectrum of the variations associated with LQTS with twelve novel variants in five genes. And also it draws attention to the frequency of the KCNQ1 c.1097G>A variant and forms the basis for new studies to determine the possible founder effect in the Turkish population. Furthermore, identifying new variants and clinical findings has importance in elaborating the roles of related genes in pathophysiology and determining the variable expression and incomplete penetration rates in this syndrome.

Prevalence of Jervell-Lange Nielsen syndrome in children with congenital bilateral sensorineural hearing loss

OBJECTIVE

Long QT syndrome (LQTS) is an inherited cardiac ion channel disorder (channelopathy) that is characterized by prolonged QT intervals on the electrocardiography (ECG) and possess the risk of sudden cardiac death (SCD). Jervell-Lange Nielsen syndrome (JLNS) is a specific subtype of LQTS that is accompanied by congenital sensorineural hearing loss, inherited autosomal recessively, and higher risk of SCD. In this study, we aimed to investigate JLNS prevalence in deaf children attending special schools for hearing loss, located in our province.

METHODS

An ECG screening program was conducted in 6 special schools for children with hearing loss in İstanbul and a total of 440 students between 6 and 18 years old were included. Corrected QT interval (QTc) was calculated using the Bazett formula. Notably, 51 students, detected with any abnormal finding on ECG, were invited to our center for a comprehensive examination.

RESULTS

A total of 8 patients were found with a prolonged QT interval. JLNS was diagnosed in 4 (0.9%) patients. In addition, 2 students had already been diagnosed with JLNS at another center earlier. The other 2 students, being siblings, were newly diagnosed with JLNS; and appropriate treatment was initiated. Genetic testing revealed a pathological homozygous mutation in KCNQ1 gene. The younger sibling (Case 1), who possessed a QTc of greater than 500 ms and a history of syncope, which was very suspicious for SCD, was implanted an implantable cardioverter-defibrillator. Propranolol treatment was initiated for both siblings.

CONCLUSION

JLNS should be carefully considered and screened, especially in patients with a history of congenital deafness.

Implantation of the Edwards SAPIEN XT and SAPIEN 3 valves for pulmonary position in enlarged native right ventricular outflow tract

OBJECTIVE

Percutaneous pulmonary valve implantation (PPVI) into right ventricle-to-pulmonary artery conduits is increasingly being performed, but a few options are available for patients with a dilated native right ventricular outflow tract (RVOT), among which is the off-label use of Ed-wards SAPIEN® valves. This study reviews the results of the SAPIEN XT and SAPIEN 3 (S3) valve implantations in the pulmonary position in patients with a dilated native RVOT.

METHODS

Between January 2015 and March 2020, PPVI procedures were performed on 129 patients. Among them, 103 (80%) had dilated native RVOT, 86 of whom were eligible for PPVI prestenting and valve implantation. Retrospective analysis was performed on 84 patients who have undergone successful PPVI implantation using the SAPIEN XT or S3 valves with dilated native RVOT.

RESULTS

The procedural success rate was 84/86 (98%). The median age was 18.7 years (8-46 years), and the median weight was 57 kg (22-102 kg). The primary underlying diagnosis was tetralogy of Fallot (n=77/84). Stenting was performed simultaneously with valve implantation in 50/84 (60%) cases-six of which were hybrid procedures-whereas prestenting was performed 3 to 14 weeks earlier in 34/84 cases. Before valve im-plantation, the median right anterior oblique and lateral diameters of the stents were 26 mm (20-32 mm) and 28 mm (21-32 mm). Valve sizes were 26 mm (n=13) and 29 mm (n=64) for XT and 29 mm (n=7) for S3. In 59 patients, an additional 1-5 ml (median 2 ml) volume was added to the valves' balloons for stabilization. In all hybrid procedures, the stent and valve were implanted in the same session. During follow-ups of 1 to 59 months (median 14 months), no deaths were reported, 3 patients developed tricuspid regurgitation secondary to the procedure, and valves continued to function in all patients.

CONCLUSION

The Edwards SAPIEN XT and S3 valves may be an alternative to PPVI in patients with dilated native RVOT.

Cryoablation with an 8-mm tip catheter for typical AVNRT in children: a single center 5-year experience

BACKGROUND

In children with typical atrioventricular nodal reentrant tachycardia (tAVNRT), cryoablation is preferred over radiofrequency ablation (RFA) because of its safety profile and acceptable long-term success rates. In this study, we have assessed the utility of 8-mm tip cryocatheters for tAVNRT ablation in our center.

METHODS

All pediatric AVNRT patients who underwent cryoablation with an 8-mm tip cryocatheter in our center between 2013 and 2018 were included. EnSite™ (St. Jude Medical Inc., St. Paul, MN, USA) was used in all patients.

RESULTS

A total of 120 patients (64 females, 53%) were included in this study, and the mean age was 13.9 years with a standard deviation of 2.5 years. Eleven patients (9.1%) had structural heart disease, and 12 patients (10%) had additional arrhythmia substrate. The mean number of effective cryolesions was 8 with a standard deviation of 2.3. Fluoroscopy was used in three patients (2.5%). There were minor complications in only four patients (3.3%)-transient first-degree atrioventricular block or transient incomplete right bundle branch block. Acute success rate of cryoablation was 108/120 (90%). In twelve patients, cryoablation was suboptimal, or it failed. The procedure was completed successfully with RFA in the same session in ten patients. Overall acute success rate of ablation (Cryo ± RFA) was 98.5%. During a mean follow-up period of 24.6 months with a standard deviation of 11.3 months, three patients had recurrence (2.5%). Time between the beginning of the effective cryolesion and termination of AVNRT was found associated with acute success of cryoablation (p = 0.013).

CONCLUSIONS

Cryoablation of AVNRT with an 8-mm tip catheter in children appears to be safe, with an acceptable acute success rate and a low recurrence rate. A faster termination of AVNRT during the cryolesion, slowing down before ending with atrioventricular block, is a good indicator for acute success.

Successful left coronary cusp cryoablation in an adolescent with premature ventrıcular extrasystoles-associated cardiomyopathy

Ventricular arrhythmias arising from coronary cusps are not uncommon. However, the mapping and ablation of outflow tract ventricular arrhythmias originating from aortic cusps can be challenging. Radiofrequency ablation of this area can cause rare but serious complications. This was a report of a 17-year-old male patient with very frequent, nonsustained ventricular tachycardia attacks and premature ventricular contraction-induced cardiomyopathy. The origin of the ventricular arrhythmia was determined to be the left coronary cusp, and the patient was treated successfully with cryoablation. In high-risk areas, cryoablation is an effective and safe alternative method.

Successful radiofrequency ablation of accessory pathway associated with left atrial appendage aneurysm in a low birthweight premature patient

Ergül Y, Öztürk E, Özgür S. Successful radiofrequency ablation of accessory pathway associated with left atrial appendage aneurysm in a low birthweight premature patient. Turk J Pediatr 2019; 61: 142-146. Tachyarrhythmias are common cardiac arrhythmias in newborns and infants. We present a premature case with a 2.4-kg birth weight, with non-immune hydrops due to supraventricular tachycardia. Despite the combination of amiodarone, esmolol and flecainide, tachyarrhythmia could not be controlled and radiofrequency ablation was applied due to left ventricular dysfunction. After the procedure the rhythm returned to normal sinus and left ventricular functions improved rapidly. The follow-up of the case continues without any problems. In this presentation, successful ablation of the accessory pathway associated with structural heart disease have been covered in the youngest and smallest patient to date.

Arrhythmia during diagnostic cardiac catheterization in pediatric patients with congenital heart disease

OBJECTIVE

Diagnostic and interventional cardiac catheterization procedures for congenital heart diseases (CHD) are becoming increasingly more popular, and arrhythmia is a well-known complication. This study was an evaluation of the incidence and causative agents of arrhythmia and the subsequent treatment strategies applied during cardiac catheterization.

METHODS

The catheterization data of all of the patients who underwent diagnostic cardiac catheterization for CHD between January 2012 and 2018 at a single center were examined retrospectively.

RESULTS

A total of 1316 children underwent diagnostic cardiac catheterization due to CHD. The median age and body weight was 18 months (6 days-21 years) and 9.9 kg (2.2-135 kg), respectively. Patients with ventricular septal defect (281 patients) and those with tetralogy of Fallot (257 patients) represented 2 major groups of the study population. In 93 (7%) patients, arrhythmia developed during cardiac catheterization. Among them, there were 58 (62%) cases of bradyarrhythmia and 35 (38%) cases of tachyarrhythmia. Arrhythmia was classified as low, high, or major, according to the adverse event severity score; the rates were 2.7%, 4.3%, and 1.2%, respectively. In 36 (39%) patients, there was no need for therapy, whereas 57 (61%) required treatment to eliminate the arrhythmia. Treatment modalities included catheter manipulation in 15, pharmacological therapy in 24, and cardioversion in 3 patients. Eleven patients required cardiopulmonary resuscitation. Temporary pacemaker implantation was required in 2 patients, while 2 others underwent permanent pacemaker implantation secondary to catheterization-related arrhythmia. There were no cases of mortality secondary to catheterization-related arrhythmia.

CONCLUSION

Diagnostic cardiac catheterization in CHD may result in various types of cardiac arrhythmias. The proper management of arrhythmias may reduce morbidity and mortality related to cardiac catheterization.

Can flecainide totally eliminate bidirectional ventricular tachycardia in pediatric patients with Andersen-Tawil syndrome?

Andersen-Tawil syndrome (ATS) is a disorder that causes episodes of muscle weakness (periodic paralysis), changes in heart rhythm, and developmental abnormalities. QT prolongation and ventricular arrhythmias, including bidirectional ventricular tachycardia (VT) and polymorphic VT, may occur. About 60% of all cases of the disorder arecaused by mutations in the KCNJ2 gene. A 13-year-old female patient was referred for frequent premature ventricular contractions. Suspicion of ATS due to dysmorphic findings, electrocardiogram changes, and periodic muscle weakness was genetically confirmed. Beta-blocker therapy was initiated as a first-line treatment for bidirectional VT and frequent polymorphic premature ventricular contractions. Despite proper treatment, the VT attacks were not brought under control. Flecainide was added to the treatment regime. The number of premature ventricular contractions was dramatically reduced with flecainide and the VT attacks completely disappeared. This patient is a rare example of ATS in our country. This article provides a description of successful management of rhythm disturbance in a patient with ATS.

Successful cryoablation of incessant fast-slow atypical atrioventricular nodal reentrant tachycardia in a child with tachycardia-induced cardiomyopathy

A 15-year-old female patient presented at the clinic with heart failure (HF). A 12-lead electrocardiogram showed a heart rate of 170 bpm; negative P waves in leads DII, DIII, aVF; and long RP tachycardia (LRPT). Echocardiography demonstrated a shortening fraction (SF) of 20%. An electrophysiology study during tachycardia revealed an atrial-His time of 52 milliseconds and a His-atrial interval of 295 milliseconds. During ventricular entrainment, the postpacing interval-tachycardia cycle length was measured at 225 milliseconds. There was a pseudo V-A-A-V response. These findings confirmed the diagnosis of atypical atrioventricular nodal re-entrant tachycardia (aAVNRT). Successful slow pathway cryoablation was performed with an 8-mm-tip cryocatheter. After 2 weeks, the SF was measured as 34%. During a 2-year follow-up period, no recurrence was observed. In conclusion, fast-slow aAVNRT should be a part of the differential diagnosis of incessant LRPT leading to HF. Cryoablation can be used successfully in cases of aAVNRT.

Atrial flutter and nonconducted bigeminy premature atrial contraction in a neonate with cardiac rhabdomyoma

During the neonatal period the majority of cardiac tumors seen are rhabdomyomas, and the clinical manifestations are notably variable. Symptoms of rhabdomyoma depend on the presence of intracardiac obstructions, myocardial involvement, or rhythm disturbances. Most cardiac rhabdomyomas regress in follow-up, but some need medical/surgical intervention during the neonatal period as a result of resistant atrial or ventricular arrhythmia. The present case study is a description of an 8-day-old neonate with atrial bigeminy that caused nonconducted premature pulse-related bradycardia, and cardiac rhabdomyoma-related resistant atrial flutter that were detected and successfully treated.

Low-Dose Computed Tomographic Imaging of Partial Anomalous Pulmonary Venous Connection in Children

Background:

In this study, we aimed to determine lobar distribution, drainage sites, and associated cardiovascular anomalies of partial anomalous pulmonary venous connection in pediatric patients using low-dose multidetector computed tomographic angiography.

Methods:

Sixty-one cases (27 female, mean age: 4.7 years) with partial anomalous pulmonary venous connection diagnosed by multidetector computed tomographic angiography were included in this study. In all patients, multidetector computed tomographic angiography examinations were performed using dual-source 256-slice scanner without sedation.

Results:

In 61 patients, 73 anomalous pulmonary veins were detected, 56 (77%) of them were right-sided and 17 (23%) were left-sided. Of 56 right-sided anomalous pulmonary veins in 49 patients, 38 (68%) drained into superior vena cava, eight (14%) into atriocaval junction, six (11%) into inferior vena cava, three (5%) into right atrium, and one (2%) into levoatriocardinal vein. Of 17 left-sided anomalous pulmonary veins in 12 patients, 16 (94%) drained into left innominate vein, and one (6%) into coronary sinus. Only seven (12%) patients had isolated partial anomalous pulmonary venous connection, whereas 54 (88%) patients had additional cardiovascular anomalies. The most common (66%) associated anomaly is atrial septal defect. The overall mean effective radiation dose was 1.12 mSv (range: 0.15-7.41 mSv), and it was 0.58 mSv (range: 0.15-0.73) in the patients younger than one-year old.

Conclusions:

The presence and course of the anomalous pulmonary veins and associated cardiovascular anomalies can be reliably detected by dual-source 256-slice multidetector computed tomographic angiography with low radiation doses.

Use of inhaled nitric oxide in pediatric cardiac intensive care unit

OBJECTIVE

Experience with administration of inhaled nitric oxide (iNO) in pediatric cardiac intensive care unit was retrospectively reviewed.

METHODS

Data from 32 pediatric patients treated with iNO between 2011 and 2012 were collected. Patients were divided into 3 groups: Group I comprised postoperative patients, Group II comprised newborns with persistent pulmonary hypertension (PPH), and Group III comprised patients with primary pulmonary hypertension (PH) or Eisenmenger's syndrome. Age, sex, weight, primary diagnosis, arterial blood sample, pulmonary artery pressure (PAP), systemic arterial pressure (SAP), and oxygen saturation levels were analyzed.

RESULTS

Groups I, II, and III included 25, 3, and 4 patients, respectively. Median weight was 8 kg (range: 3-40 kg), and median age was 7 months (range: 2 days-10 years). On average, iNO treatment was initiated at the 12th hour after admission to the unit (range: 1-48 hours) and continued for a median duration of 24 hours (range: 12-168 hours). Systolic PAP was 40±15 mmHg, mean SAP was 57±18 mmHg, PAP/SAP ratio was 0.69, and oxygen saturation levels were 88% prior to iNO treatment. Following iNO treatment, PAP decreased to 24±9 mmHg (p<0.05), PAP/SAP ratio decreased to 0.4 (p<0.05), SAP showed no change (60±12 mmHg), and saturation levels increased to 98% (p<0.05). Seven patients died during follow-up (Group I, n=5; Group II, n=1; Group III, n=1).

CONCLUSION

iNO seems to effectively reduce PAP, and can be used effectively and safely to prevent pulmonary hypertensive crises in pediatric cardiac intensive care units.

Spontaneous Remission of Congenital Complete Atrioventricular Block in Anti-Ro/La Antibody-Negative Monozygotic Twins: Case Report

Background:

Congenital complete atrioventricular block without any structural heart disease and anti-Ro/La negativity is very rare. Discordant complete atrioventricular block, which is more frequently defined in the literature as an autoimmune mechanism, is much more rare in monozygotic twins.

Case Report:

The 26-year-old healthy mother had given birth in her first spontaneous, uneventful pregnancy to monozygotic twins at week 35. While the first twin’s physical examination proved her to be normal with a pulse rate consistent with her age, the second twin had a pulse rate of approximately 40 beats/minute.The patient was confirmed to have congenital complete atrioventricular block.

Conclusion:

Despite this case appears to be an isolated one, a discordant complete atrioventricular block regression without any autoimmune evidence should be included in the differential diagnosis of bradycardia in infants.

Multidetector Computed Tomographic Angiography Imaging of Congenital Pulmonary Venous Anomalies: A Pictorial Review

Congenital pulmonary venous anomalies are not uncommon that can occur either in isolation or in association with different forms of congenital heart disease. Clinical presentation of these anomalies may vary from the relatively benign single anomalous partial pulmonary venous return to life-threatening critical obstructed total anomalous pulmonary venous return. Accurate delineation of these anomalies and accompanied cardiovascular anomalies are crucial to guide decision making in these patients. Low-dose high-pitch dual-source 256-detector multidetector computed tomographic angiography is a fast and reliable imaging modality allowing comprehensive noninvasive anatomic imaging in neonates and children with congenital pulmonary venous anomalies with lower radiation doses and should be preferred for these patients after transthoracic echocardiography.

The use of neonatal extracorporeal life support in pediatric cardiac intensive care unit

AIM

The aim of the study is to evaluate extracorporeal life support system (ECLS) employed in neonates in pediatric cardiac intensive care unit.

MATERIAL AND METHODS

Twenty-five neonates that required ECLS in between November 2010 and November 2015 were evaluated.

RESULTS

The median age was 12 days (range 3-28 days) and the median body weight was 3 kg (range 2.5-5 kg). Venoarterial ECLS was performed in all of the cases. Ascendan aorta-right atrial cannulation in 22 patients and neck cannulation in three patients were performed. The reason for ECLS was E-CPR in two patients, inability to wean from cardiopulmonary bypass (CPB) in seven patients, respiratory insufficiency and hypoxia in nine patients, low cardiac output (LCOS) in seven patients. Median duration of ECLS was four days (range 1-15). Hemorrhagic complications developed in 15, renal complications in 13, pulmonary complications in 12, infectious complications in 11, neurologic complications in three and mechanical complications in two of the patients. Weaning was successful in 15 of the patients. Eleven patients were successfully discharged.

CONCLUSION

ECLS is an important treatment option that is performed successfully in many centers around the world to maintain life support in patients unresponsive to medical treatment. The utilization of this modality especially in newborns with congenital heart disease should be taken into consideration.

A rare pathology: Levoatriocardinal vein

OBJECTIVE

Levoatriocardinal vein (LACV) is a rare cardiac pathology that represents a connection between the pulmonary venous and cardinal systems. The aim of the present study was to discuss morphological and clinical characteristics, as well as diagnostic methods, of experience with LACV.

METHODS

Records of 11 patients (4 male, 7 female; mean age 79±1.83 days; range 1-390 days) diagnosed with LACV between 2010 and 2014 were retrospectively reviewed. Presence of LACV was confirmed with echocardiography. The primary obstructive lesion associated with cardiac defects and the integrity of the interatrial septum was identified in each patient with left-sided obstruction.

RESULTS

Mean weight was 4.4±0.4 kg (range: 2-8). Age at presentation was under 1 year in 82% of patients. Nine patients had left-sided obstruction, and 2 had normal intracardiac anatomy and pulmonary venous return. In patients with left-sided obstruction, LACV was initially demonstrated with echocardiographic evaluation, performed in apical 4-chamber, high parasternal, and subcostal views. Atrial septum was restrictive or intact in patients with left-sided obstructions. LACV originated directly from the left atrium in all patients.

CONCLUSION

Levoatriocardinal vein is an extremely rare cardiac pathology, presenting almost exclusively in patients with left-sided obstructive lesions. In patients with left-sided obstructions, LACV must be kept in mind. It may also present in patients with normal intracardiac anatomy and pulmonary venous return.

Transesophageal echocardiography experience in thepediatric age group in a tertiary cardiac center

BACKGROUND/AIM

The aim of this study was to evaluate the transesophageal echocardiography (TEE) findings of pediatric patients in a tertiary center where complex congenital heart surgery and interventional procedures have been performed.

MATERIALS AND METHODS

All TEE studies performed between December 2009 and December 2014 were reviewed retrospectively. Patients were divided into 3 groups: perioperative, during interventional procedures, and due to other reasons. Demographic features, transthoracic echocardiography (TTE) reports, TEE reports, change in decision after TEE evaluation, and related complications were recorded.

RESULTS

A total of 703 patients who had TEE evaluation were included in the study; 51% were female and 49% were male. The median age was 90 months (2 months to 18 years). TEE was performed perioperatively in 430 patients (61%), during cardiac catheterization-angiography and electrophysiology studies in 181 patients (26%), and due to other reasons in 92 patients (13%). Mismatches between TTE and TEE or changes in decision after TEE evaluation were present in 45 patients (10.4%) who had perioperative TEE, in 10 patients (5.5%) who had TEE during interventional procedures, and 22 patients (24%) who had TEE evaluation due to other reasons. No major complications were detected.

CONCLUSION

Information acquired by TEE increases the clarity of future plans for the patient and helps to decrease the mortality and morbidity caused by unnecessary procedures.

The use of flecainide in critical neonates and infants with incessant supraventricular tachycardias

OBJECTIVE

This study aimed to evaluate the efficacy of flecainide therapy in neonates and infants with drug resistant incessant supraventricular tachycardia.

METHODS

The study included 11 neonates and infants who received medical and/or ablation therapy between January 2010 and December 2013. Mean patient age and weight were 101.6 ± 96 days and 5.3 ± 1.9 kg respectively. Of the 12 patients, 5 underwent ablation between January 2010 and December 2011, and 6 were treated medically between January 2012 and December 2013. Mean follow-up time was 18 months (6 months-4 years).

RESULTS

The antiarrhythmic agent flecainide only became available in Turkey in 2012, and the most noteworthy point was its addition to the therapy administered prior to ablation (adenosine, esmolol-propranolol, propafenone, amiodarone and cardioversion). In all 6 patients admitted between January 2012 and December 2013, refractory SVT was successfully treated with the administration of a triple therapy regimen of esmolol-propranolol, amiodarone and flecainide. One patient with myocarditis developed an atrial flutter complicated by a concealed accessory pathway and was put on extracorporeal membrane oxygenation (ECMO) support due to cardiopulmonary failure. The SVT was terminated, but the patient died on the fifteenth day of ECMO support. One patient with recurrent tachycardia, who had previously undergone ablation for a complex cardiac anomaly and Wolf-Parkinson-White syndrome, was treated with ablation again. No recurrence of tachycardia was observed in any of the other 9 patients.

CONCLUSION

It appears that the use of propranolol-esmolol and amiodarone combined with flecainide in the medical treatment of drug-resistant SVT may reduce the need for ablation in critical neonates and infants.

[Hypertrophic cardiomyopathy and Costello syndrome: review of recent related literature with case report]

Costello syndrome is a rare syndrome characterized by failure to thrive, short stature, mental motor retardation, characteristic facial features, macrocephaly, a short neck, loose soft skin with deep palmar and plantar creases, and hypertrichosis. Cardiac involvement is seen in almost two thirds of patients, and is a determinant for the prognosis of Costello syndrome. The most common cardiac anomalies are pulmonary stenosis, hypertrophic cardiomyopathy, atrial septal defect, ventricular septal defect and arrhytmia. In this report, we present a 14-month-old female pediatric patient with hypertrophic cardiomyopathy, clinically and genetically diagnosed with Costello syndrome. The report also contains a review of recent related literature.

Heart rate variability improvement in children using transcatheter atrial septal defect closure

Objective:

We evaluated autonomic behavior by examining heart rate variability (HRV) in the time domain and frequency domain in pediatric patients who underwent transcatheter closure of atrial septal defect (ASD).

Methods:

A prospective study design was used. Holter ECG was performed in a control group of 30 healthy subjects and a group of 47 patients who underwent transcatheter ASD closure. ECG was taken one day before, one day after, and six months after the procedure to evaluate changes in the time domain [SDNN, rMSSD, NN, pNN50(%), and SDANN] and frequency domain (VLF, LF, HF, VHF, and LF/HF) in the patient group. Student’s t-test was used to evaluate changes prior to and after the procedure.

Results:

There were 28 females (60%) in the patient group and 21 females (70%) in the control group. The mean age and weight of the participants in the patient group were 9.61±4.72 years and 32.40±19.60 kg, respectively; the mean age and weight of the control subjects were 10.43±5.31 years and 32.83±13.00 kg, respectively. In both the time domain and frequency domain analyses, the patient group values were found to be lower than those in the control group prior to the procedure; the values in the patient group were found to approach the values in the control group following the procedure. By the sixth month, the values in the patient group reached the control levels with no statistically significant difference (SDNN: 145±0.84, 137.50±42.50; r MSSD: 72.18±48.22, 58.14±28.49; SDANN: 125.13±13.50, 122.40±41.06; VLF: 112.85±29.07, 114.41±98.39; LF: 50.40±24.09, 45.69±15.13; HF: 39.28±19.86, 44.29±13.14; VHF: 10.29±4.24, 9.99±6.47; LF/HF: 1.90±1.44, 1.24±0.81; p>0.05).

Conclusion:

The transcatheter closure of secundum ASDs was found to have a positive effect on HRV. Consequently, it may contribute to reduced mortality and morbidity. We can conclude that in children, HRV recovers approximately six months after transcatheter ASD closure.

Successful transvenous lead extraction using the Evolution System in a 17-kg child

Despite technological advancements in the field of pacemaker lead extraction, available data on pediatric patients is limited, and risk of failure and severe complications remains high. In this report, we present the case of a male patient who, at five months old, had been transvenously implanted with a single-chamber ventricular pacemaker due to complete atrioventricular block. At 7-year of age, the patient was referred to us with growth-related lead tension, severe tricuspid insufficiency, and weak battery. We extracted the lead using the Evolution System and replaced the unit with a dual-chamber pacemaker with a SelectSecure lead. This new system can be used for lead extraction even in low-weight pediatric patients with congenital heart disease. Using a thin, lumenless SelectSecure lead appears to reduce the risk of venous obstruction.

Transcatheter patent ductus arteriosus closure with echocardiographic guidance: can radiation exposure be reduced?

OBJECTIVES

The radiation dose from interventional cardiac catheterization is particularly relevant when treating children because of their greater radiosensitivity compared to adults. The transcatheter closure of patent ductus arteriosus (PDA), as well as other more complex pediatric interventions, have raised concerns regarding radiation exposure, particularly relevant when treating children. The purpose of this study is to show how to perform the transcatheter closure of PDA in children while giving less ionized radiation and to prove that the amount of radiation and contrast material can be reduced.

STUDY DESIGN

Following appropriate device selection based on PDA morphology and diameter, transthorasic echocardiography images and control aortography findings were analyzed. The following devices were used during the procedure: Gianturco coils (10/63), an Amplatzer Duct Occluder (ADO, 31/63), Flipper coils (19/63), and an Amplatzer vascular plug (3/63).

RESULTS

The scopy time, radiation dose, and contrast were 12 ± 6.4 mins, 28.1 ± 14.7 cmGy/cm²/kg, and 4.2 ± 2.3 cc/kg, respectively. In the control aortography shortly after the procedure, residual shunt was detected at various levels in 39.7% of patients, and 9.5% demonstrated residual shunt in real-time echocardiography. In the control aortography, the exposure to radiation was 13.3% of the total, and the amount of infused contrast was 27.2% of the total.

CONCLUSION

Patients may be exposed to less radiation and contrast material if an echocardiographic evaluation, instead of a final control aortography injection, is performed after the transcatheter closure of PDA.

Anatomically corrected malposition of the great arteries: two case reports

Anatomically corrected malposition of the great arteries (ACMGA) is defined as parallel arising of aorta and main pulmonary artery (PA) roots although ventriculoarterial connection is normal. Abnormally related aorta arises from the left ventricle, while abnormally related PA arises from the right ventricle. It can be diagnosed with via echocardiography. In some cases, additional imaging modalities such as computerized tomographic angiography and magnetic resonance are required. In this article, we presented two cases of ACMGA, 5-month-old boy and 1-month-old girl. We wanted to point out the importance of differential diagnosis of other great artery anomalies from this rare pathology.

Atypical presentation of an infant with idiopathic pulmonary arterial hypertension: pericardial tamponade

In this report, we present a five-month-old female patient with a diagnosis of idiopathic pulmonary arterial hypertension (IPAH). This patient was accepted by our clinic after a sudden deterioration in her clinical condition. We performed echocardiography and observed a 17 mm pericardial fluid near the left ventricle posterior wall, which was seen to compress the right atrium and right ventricle outflow tract. Cardiac contraction was impaired, the interventricular septum was hypertrophic and the right ventricle systolic pressure measured by tricuspid regurgitation was at systemic level. Pericardiocentesis was performed for pericardial tamponade, and a drainage tube was placed in the pericardium. Cardiac catheterization was performed before and after nitric oxide inhalation, and there were no changes in the parameters of pulmonary vascular resistance, pulmonary vascular resistance/systemic vascular resistance ratio and mean pulmonary arterial pressure. No cardiac lesion that could cause PAH was detected during catheterization. Under mechanical ventilatory support and intensive medical therapy, the patient died on her 16th day of hospitalization. The importance of our case is that it is the first infantile case presenting with pericardial tamponade associated with IPAH.

Being ambulatory does not secure respiratory functions of Duchenne patients

Aim:

The aim of this work was to assess the respiratory functions of ambulatory Duchenne patients and to propose an earlier time period for intervention.

Materials and Methods:

Lung functions and North Star Ambulatory Assessment (NSAA) scores of Duchenne patients were evaluated simultaneously.

Results:

Thirty ambulatory Duchenne patients were included in this study. NSAA scores of the patients were directly correlated with arm abduction, arm adduction, and shoulder flexion strengths. Forced expiratory volume in 1 second percent predicted and forced vital capacity (FVC) percent predicted correlated inversely to age and to the NSAA score. Twelve of 13 patients with FVC values lower than 80% of predicted had NSAA scores below 24 points. None of the patients who were younger than 7 years had FVC values lower than 80% of predicted.

Conclusion:

Annual spirometry is necessary for Duchenne patients older than 6 years regardless of the ambulatory status.

[A rare cause of recurrent wheezing and respiratory distress: Scimitar syndrome]

Scimitar syndrome is characterized by partial or total anomalous pulmonary venous return from the right lung. We present a 15-month-old boy who was diagnosed with Scimitar syndrome after examinations for recurrent wheezing and respiratory distress. The chest radiograph showed a scimitar sign in the right hemithorax, obscuring the contours of the right atrium. Echocardiography showed dilatation of the right heart cavities and increased flow in the inferior vena cava, without a cardiac abnormality. The patient underwent cardiac catheterization for radiographic and hemodynamic evaluations, during which a scimitar vein was detected, draining the right pulmonary veins to the inferior vena cava. Coil occlusion was performed on the abnormal artery arising from the infradiaphragmatic aorta. The patient was referred to surgery for repair of the anomalous pulmonary venous return and resection of the sequestered pulmonary segment.

Etanercept-induced encephalopathy in a 7-year-old child

Adverse events were reported in various patients treated with etanercept, including infections (sepsis and tuberculosis), malignancies (e.g., lymphoma), demyelinating disorders, and autoimmune diseases. Only two adult patients with etanercept-related encephalopathy were previously reported. We describe a 7-year-old patient who developed encephalopathy immediately after his third dose of etanercept. To the best of our knowledge, ours is the first report of a pediatric patient with a diagnosis of systemic arthritis and who developed etanercept-related encephalopathy.

Cardiac arrest after anesthetic management in a patient with hereditary sensory autonomic neuropathy type IV

Hereditary sensory autonomic neuropathy type IV is a rare disorder with an autosomal recessive transmission and characterized by self-mutilation due to a lack in pain and heat sensation. Recurrent hyperpyrexia and anhydrosis are seen in patients as a result of a lack of sweat gland innervation. Self-mutilation and insensitivity to pain result in orthopedic complications and patients undergone recurrent surgical interventions with anesthesia. However, these patients are prone to perioperative complications such as hyperthermia, hypothermia, and cardiac complications like bradycardia and hypotension. We report a 5-year-old boy with hereditary sensory autonomic neuropathy type IV, developing hyperpyrexia and cardiac arrest after anesthesia.

[The comparison a 16-year follow-up results of balloon angioplasty for aortic coarctation in children of different age groups: a single-center experience]

OBJECTIVE

Pediatric patients with different age groups who underwent balloon angioplasty for aortic coarctation were evaluated for recoarctation, aneurysm, peripheral arterial injuries and concomitant diseases.

METHODS

From January 1994 to 2010, 80 patients with aortic coarctation (native/recoarctation) were evaluated, retrospectively. According to age at angioplasty, patients were divided into three groups: Group A (0-3 months, n=29, 25 male/4 female, average weight 4±1.2 kg), Group B (3-12 months, n=20, 15 male/5 girls, average weight 6.5±1.9 kg) and Group C (> 1 year, n= 31, 15 male/16 girls, average weight 22.8±16 kg). The patients were followed with echocardiography and clinical signs. The data of the native and recoarcted patients and also those in three different age groups were analyzed by using Chi-square, Kruskal-Wallis, and Student t tests.

RESULTS

Peak systolic pressure gradient was reduced from 42±17 mmHg to 6.2±6 mmHg after balloon angioplasty (p<0.001) [n=80, 56 (70%) native, 24 (30%) recoarctation]. There was no difference between groups for early success. None of them did require immediate surgery. There were ventricular septal defect in 23 (28.7%), bicuspid aorta in 18 (22.5%), patent ductus arteriosus in 11 (13.7%) patients. Two patients had Turner's syndrome. Mean follow-up period was 74±56 months. While recoarctation developed in 20 (25%), [12 (60%) in Group A, 5 (25%) in Group B and 3 (15%) in group C, incidence was higher in the 0-3 months age group (p=0.018). Femoral artery occlusion and aneurysm were developed in 6 (7.5%) and 4 (5%) patients, respectively, and all of them were under 1-year-old.

CONCLUSION

Balloon angioplasty can be used a method in treatment of native aortic coarctation and postoperative restenosis. Especially, children under 3 months should be monitored closely after the procedure for recoarctation, aneurysms and peripheral artery problems.

[Acute cyanosis after transcatheter balloon valvuloplasty: toxic methemoglobinemia due to local prilocaine use]

Methemoglobinemia is characterized by varying degrees of cyanosis due to increased hemoglobin concentrations containing oxidized iron. Prilocaine is a widely used local anesthetic and can cause methemoglobinemia in infants even in therapeutic doses. We present two female infants (younger than 2 months) who developed severe cyanosis after transcatheter pulmonary balloon valvuloplasty and were diagnosed with toxic methemoglobinemia. Both infants were anesthetized with local prilocaine application before balloon valvuloplasty. Methemoglobin levels of the patients were measured as 49.6% and 37.7%, respectively. Both were successfully treated with intravenous methylene blue and ascorbic acid.