Very long-term follow-up after aortic stenting for coarctation of the aorta

INTRODUCTION AND OBJECTIVES

Stent implantation is the preferred treatment in older children and adults with aortic coarctation (CoA). We aimed to determine the incidence of very late events after CoA stenting.

METHODS

We analyzed a cohort of CoA patients who underwent stent implantation at our center between 1993 and 2018. Patients were periodically followed up in outpatient clinics, including computed tomography (CT) and fluoroscopy assessment.

RESULTS

A total of 167 patients with CT and fluoroscopy data were included: 83 (49.7%) were aged ≤ 12 years and 46 (28%) were female. The mean clinical follow-up time was 17±8 (range 4-30) years and the mean time to CT/fluoroscopy was 11±7 years. Aortic aneurysm was present in 13% and was associated with the PALMAZ stent (OR, 3.09; 95%CI, 1.11-9.49; P=.036) and the stented length (OR, 0.94; 95%CI, 0.89-0.99; P=.039). Stent fracture was frequent (34%), but was not related to the presence of aneurysm. Stent fracture was associated with young age (OR, 3.57; 95%CI, 1.54-8.33; P=.003), male sex (OR, 4.00; 95%CI, 1.51-12.5, P=.008) and inversely with the PALMAZ stent (OR, 0.29; 95%CI, 0.12-0.67, P=.005). Reintervention was lower in adults (10%), mainly related to aneurysms. Those treated when aged ≤ 12 years had higher reintervention rates (43%) due to recoarctation somatic growth.

CONCLUSIONS

This long-term follow-up study of CoA patients treated with stenting revealed a significant incidence of late events. Reintervention rates were higher in patients treated at younger ages. Periodic imaging surveillance appears to be advisable.

Epidemiology and outcomes of pediatric cardiac arrest in a cardiovascular unit at a public hospital in Argentina

BACKGROUND

Children with congenital heart disease present a higher frequency of cardiorespiratory arrest (CRA) than the general pediatric population. The epidemiology of CRA is not exactly known in our setting, nor are the mortality risk or the neurological evolution factors.

OBJECTIVE

To describe the epidemiology and outcomes associated with pediatric cardiopulmonary resuscitation in a cardiovascular recovery unit. The primary endpoint was the survival to discharge and the secondary endpoints were the return to spontaneous circulation, the survival at 24 hours and the remote neurological condition.

METHODS

Descriptive, prospective, longitudinal cohort study in children under 18 years of age who required cardiopulmonary resuscitation between 2016 and 2019. Demographic variables, characteristics of cardiopulmonary arrest, resuscitation and outcome were analyzed. An uni- and multivariate analysis was performed comparing survivors and deceased.

RESULTS

Out of 1,842 hospitalized patients, 4.1% presented CRA. Fifty patients with complete records were analyzed. Seventy-eight percent (39) returned to spontaneous circulation with a high survival rate of 46%. Resuscitation > 6 min and the use of vasoactive drugs were predictors of mortality; 16/23 patients were followed up, 10 of them with normal development for age at 6 months, six had pervasive developmental disorder.

CONCLUSIONS

4.1% of patients presented CRA, with a rate of 3.4 CRA per 1,000 patient-days. Survival at hospital discharge (n = 50) was 46%. Resuscitation > 6 min and the use of vasoactive drugs were independent predictors of mortality. At six months, 63% had normal neurological development for age.

Prognosis factors in heart-lung transplantation: 30 years experience in a reference center

INTRODUCTION

Heart-lung transplantation has shown a progressive decrease in the number of procedures. There is a lack of information about this field in Spain. The main goal of this study is to analyze the experience of a national reference hospital.

METHODS

We performed a retrospective study of a historical cohort of heart-lung transplanted patients in a single center, during a 30 years period (from 1990 to 2021). The associations between variables were evaluated using the χ2 test or Fisher's exact test. Survival was analyzed using the Kaplan-Meier method. Differences were evaluated using the log-rank test and multivariate analysis with the Cox method.

RESULTS

A decrease in the number of procedures performed in the last decade was observed [2000-2009: 19 procedures (44.2%); 2010-2021: 15 procedures (34.8%)]. Early postoperative mortality was 23.3%, falling to 13.3% from 2010. In-hospital mortality was 41%, falling to 33% from 2010. Main factors related to higher mortality: previous thoracic surgery, corticosteroid therapy, extracorporeal circulation (ECLS) greater than 200 min, ischemia time greater than 300 min, and tracheal dehiscence (p < 0.005). Overall survival at one, five, and ten years was 58%, 44.7%, and 36.1%, respectively. Factors associated with lower survival rates: previous thoracic surgery, male donor, extracorporeal circulation greater than 200 min, ischemia time greater than 300 min, tracheal dehiscence and weight difference (p < 0.005).

CONCLUSIONS

There has been a progressive decrease in the number of heart-lung transplantations, being more evident in the last decade, but showing an improvement in both mortality and survival.

Univentricular hearts not undergoing Fontan: the type of palliation matters

INTRODUCTION AND OBJECTIVES

There is scarce information on patients with single ventricle physiology (SVP) and restricted pulmonary flow not undergoing Fontan circulation. This study aimed to compare survival and cardiovascular events in these patients according to the type of palliation.

METHODS

SVP patient data were obtained from the databases of the adult congenital heart disease units of 7 centers. Patients completing Fontan circulation or developing Eisenmenger syndrome were excluded. Three groups were created according to the source of pulmonary flow: G1 (restrictive pulmonary forward flow), G2 (cavopulmonary shunt), and G3 (aortopulmonary shunts±cavopulmonary shunt). The primary endpoint was death.

RESULTS

We identified 120 patients. Mean age at the first visit was 32.2 years. Mean follow-up was 7.1 years. Fifty-five patients (45.8%) were assigned to G1, 30 (25%) to G2, and 35 (29.2%) to G3. Patients in G3 had worse renal function, functional class, and ejection fraction at the first visit and a more marked ejection fraction decline during follow-up, especially when compared with G1. Twenty-four patients (20%) died, 38 (31.7%) were admitted for heart failure, and 21 (17.5%) had atrial flutter/fibrillation during follow-up. These events were more frequent in G3 and significant differences were found compared with G1 in terms of death (HR, 2.9; 95%CI, 1.14-7.37; P=.026) and atrial flutter/fibrillation (HR, 2.9; 95%CI, 1.11-7.68; P=.037).

CONCLUSIONS

The type of palliation in patients with SVP and restricted pulmonary flow not undergoing Fontan palliation identifies distinct profiles. Patients palliated with aortopulmonary shunts have an overall worse prognosis with higher morbidity and mortality.

Perioperative stress and anxiety in parents of children operated on for congenital heart disease

INTRODUCTION

Levels of stress and anxiety suffered by parents of children with congenital heart disease (PCUCS) during their children's admission for cardiac surgery may be higher than those suffered by other parents who go through the same experience.

OBJECTIVE

General objective of this study was to measure the stress and anxiety suffered by PCUCS and parents of children undergoing renal surgery (PCURS) in relation to the intervention of their children. The specific objective of the quantitative study was to compare global stress and anxiety according to sex, time of the perioperative period, and cohort. The general objective of the qualitative section is to explore the experience that PCUCS and PCURS have during their hospital stay and to identify the specific factors that influence the genesis of stress and anxiety.

METHOD

A cohort study was carried out in which PCURS and PCUCS were included. The quantitative part was performed by comparing the scores of three questionnaires that measure stress levels (PSS-14), state anxiety (STAIE) and trait anxiety (STAIR) throughout three perioperative moments. At the same time, a qualitative study was carried out with semi-structured interviews and collection of diaries on which a descriptive phenomenological analysis was carried out, according to Munhall. The analysis of the text was carried out according to Colaizzi.

RESULTS

Stress and anxiety levels were significantly higher in PCUCS compared to PCURS. Mothers in the cardiac cohort were those with the highest scores on all scales. In the qualitative study, four themes emerged: "stress and anxiety from the moment of diagnosis", "surgical intervention as a critical moment", "harshness of the postoperative period in the Intensive Care Unit" and "joy and gratitude versus dependence and fear for the future".

CONCLUSIONS

PCUCS suffer higher levels of stress and anxiety than PCURS, being the mothers of the cardiac cohort those who suffer these disorders with greater intensity. This study can constitute a starting point to develop strategies that cover these parental needs.

Nutrition in congenital heart disease: consensus document

INTRODUCTION

The prevalence of malnutrition among infants with congenital heart disease (CHD) is high. Early nutritional assessment and intervention contribute significantly to its treatment and improve outcomes. Our objective was to develop a consensus document for the nutritional assessment and management of infants with CHD.

MATERIAL AND METHODS

We employed a modified Delphi technique. Based on the literature and clinical experience, a scientific committee prepared a list of statements that addressed the referral to paediatric nutrition units (PNUs), assessment, and nutritional management of infants with CHD. Specialists in paediatric cardiology and paediatric gastroenterology and nutrition evaluated the questionnaire in 2 rounds.

RESULTS

Thirty-two specialists participated. After two evaluation rounds, a consensus was reached for 150 out of 185 items (81%). Cardiac pathologies associated with a low and high nutritional risk and associated cardiac or extracardiac factors that carry a high nutritional risk were identified. The committee developed recommendations for assessment and follow-up by nutrition units and for the calculation of nutritional requirements, the type of nutrition and the route of administration. Particular attention was devoted to the need for intensive nutrition therapy in the preoperative period, the follow-up by the PNU during the postoperative period of patients who required preoperative nutritional care, and reassessment by the cardiologist in the case nutrition goals are not achieved.

CONCLUSIONS

These recommendations can be helpful for the early detection and referral of vulnerable patients, their evaluation and nutritional management and improving the prognosis of their CHD.

Prevalence of congenital heart disease in relation to height above sea level in a region of Colombia

INTRODUCTION

Congenital heart diseases are the most common congenital disorders in the world population, they generally manifest after birth. Altitudes between 2,500-3,500 meters above sea level have been linked to the high incidence of congenital heart diseases such as patent ductus arteriosus, atrial septum defects, and ventricular septum defects.

OBJETIVES

To characterize clinically and sociodemographically the patients diagnosed with congenital heart disease from low, moderate and high altitudes in a regional hospital in Colombia.

METHODOLOGY

Observational, descriptive retrospective study. All patients under 18 years of age with a diagnosis of congenital heart disease, treated at the San Rafael de Tunja University Hospital between 2015 and 2021, were included.

RESULTS

51.9% of the patients were male, 16.3% had a history of prematurity and 9.1% had a diagnosis of Down syndrome. The most frequent heart diseases were: persistent ductus arteriosus 35.1%, followed by ventricular communication representing 21.6% and intra-atrial communication with 19.7%).

CONCLUSIONS

They must eestablish strategies such as screening and timely diagnosis of congenital heart disease in at-risk populations in order to improve the life prognosis of patients and the outcome of the disease.

Cardiac tomography-echocardiography imaging fusion: a new approach to congenital heart disease

INTRODUCTION AND OBJECTIVES

Diagnosis, management, and surgical decision-making in children and adults with congenital heart disease are largely based on echocardiography findings. A recent development in cardiac imaging is fusion of different imaging modalities. Our objective was to evaluate the feasibility of computed tomography (CT) and 3-dimensional (3D) transthoracic echocardiography (TTE) fusion in children and adults with congenital heart disease.

METHODS

We prospectively included 14 patients, 13 of whom had congenital heart disease, and who underwent both CT and 3D TTE as part of their usual follow-up. We described the steps required to complete the fusion process (alignment, landmarks, and superimposition), navigation, and image evaluation.

RESULTS

Median age was 9.5 [2.7-15.7] years, 57% were male, and median body surface area was 0.9 m² [0.6-1.7]. Congenital heart disease was classified as simple (n=4, 29%), moderate (n=4, 29%), or complex (n=6, 42%). 3D TTE-CT fusion was successful in all patients. Median total time to complete the fusion process was 735 [628-1163] seconds, with no significant difference according to the degree of complexity of the defects. Landmarks were significantly modified in complex congenital heart disease.

CONCLUSIONS

We established the feasibility and accuracy of 3D TTE-CT fusion in a population of children and adults with a variety of congenital heart diseases. The simultaneous visualization of many intracardiac structures may help to understand the anatomical features of congenital heart disease without limitations regarding age, weight, or complexity of the congenital defects.

Central venous-to-arterial CO2 difference as a biomarker of outcome in children who underwent surgery for congenital heart disease

BACKGROUND

In congenital heart surgery, low cardiac output syndrome (LCOS) is a major cause of morbidity in the immediate post-operative period. A decrease in cardiac output leads to an increase in tissue oxygen consumption. Several biomarkers such as venous oxygen saturation (SvO2), arteriovenous oxygen difference (DavO2), and lactate can assess tissue perfusion in the presence of LCOS. Recently, central venous to arterial CO2 difference (ΔCO2) has been proposed as a biomarker of tissue ischemia that could be used as a predictor of death in neonatal patients. This study aimed to analyze the relationship between ΔCO2 and immediate post-operative outcomes in pediatric patients undergoing congenital heart surgery and its correlation with DavO2, SvO2, and lactate.

METHODS

We conducted a longitudinal study of patients aged 0-18 years who underwent congenital heart surgery with or without cardiopulmonary bypass at the Instituto Nacional de Pediatría, from March 2019 to March 2021.

RESULTS

Eighty-two patients were included; the median age was 17 months. About 59% had a ΔCO2 ≥ 6 mmHg. Patients with ΔCO2 ≥ 6 mmHg had a vasoactive-inotropic score > 5 (p < 0.001), DavO2 > 5 mL/dL (p = 0.048), and lactate > 2 mmol/L (p = 0.027), as well as a longer hospital stay (p = 0.043). Patients with ΔCO2 > 6 mmHg and vasoactive-inotropic score ≥ 10 were 12.6 times more likely to die.

CONCLUSION

ΔCO2 is a good marker of tissue hypoperfusion and outcome in the post-operative period of congenital heart surgery.

Fluid overload as a predictor of morbidity and mortality in pediatric patients following congenital heart surgery

BACKGROUND

Patients undergoing congenital heart surgery with cardiopulmonary bypass frequently require the administration of intravenous fluids and blood products due to hemodynamic instability. Correctly performed fluid resuscitation can revert the state of tissue hypoperfusion in the different organs. However, excessive fluid administration and acute kidney injury may promote fluid overload (FO) and increase the risk of complications, hospital stay, and mortality.

METHODS

We conducted a prospective longitudinal study of pediatric patients with congenital heart surgery and cardiopulmonary bypass in the Pediatric Cardiac Intensive Care Unit (PCICU), Instituto Nacional de Pediatría, from July 2018 to December 2019. Fluid overload was quantified every 24 hours during the first 3 days of stay at the PCICU and expressed as a percentage. We recorded PCICU stay, days of mechanical ventilation, and mortality as outcome variables.

RESULTS

We included 130 patients. The main factors associated with fluid overload were age < 1 year (p < 0.001), weight < 5 kg (p < 0.001), and longer cardiopulmonary bypass time (p = 0.003). Patients with fluid overload ≥ 5% had higher inotropic score (p < 0.001), higher oxygenation index (p < 0.001), and longer mechanical ventilation time (p < 0.001). Fluid overload ≥ 5% was associated with higher postoperative mortality (odds ratio 89, p = 0.004).

CONCLUSIONS

Fluid overload can be used as a prognostic factor in the evolution of pediatric patients undergoing congenital heart surgery since it is associated with increased morbidity and mortality.

Percutaneous pulmonary valve implant: Two Colombian case reports

Los pacientes con cardiopatías congénitas que afectan la continuidad del ventrículo derecho con la arteria pulmonar deben someterse con frecuencia a intervenciones debido a la limitada vida útil de los conductos quirúrgicos, lo que lleva al desarrollo de disfunción ventricular derecha por cambios en la geometría ventricular y predisposición a arritmias letales, con el consiguiente riesgo de reintervenciones. El implante valvular percutáneo pulmonar es una nueva alternativa terapéutica, menos invasiva en comparación con la quirúrgica, para pacientes seleccionados. Se realiza una revisión de las publicaciones médicas actuales disponibles y se describe la experiencia inicial del implante valvular pulmonar percutáneo en un centro colombiano de alta complejidad para el tratamiento de enfermedades cardiovasculares, en dos pacientes con disfunción del homoinjerto aórtico en posición pulmonar con doble lesión valvular, en los cuales el implante valvular pulmonar percutáneo fue una conducta exitosa. Se eligió a pacientes con cardiopatías congénitas, conductos quirúrgicos disfuncionales con estenosis o insuficiencia pulmonar significativa, y disfunción y dilatación ventricular derechas. Se empleó la técnica regular para el implante de la válvula pulmonar Melody, sin documentarse complicaciones durante el procedimiento ni al año de seguimiento. El implante percutáneo de la válvula pulmonar es un gran avance en el tratamiento de pacientes con cardiopatías congénitas, con resultados favorables a corto y mediano plazos, lo cual hace posible la restauración de la función ventricular con riesgo mínimo, frente al reemplazo quirúrgico en pacientes seleccionados.

Patients with congenital heart disease that involves reconstruction of the right ventricular outflow tract must frequently undergo interventions derived from the limited useful life of the surgical canals, which leads to the development of right ventricular dysfunction due to changes in the ventricular geometry and predisposition to lethal arrhythmias, with the consequent risk of reinterventions. The percutaneous pulmonary valvular implant is a new therapeutic alternative, less invasive, compared to surgery, for selected patients. A review of the available literature is made and the initial experience of percutaneous pulmonary valve implantation in a Colombian center of high complexity for the treatment of cardiovascular diseases is described, in two patients with aortic homograft dysfunction in a pulmonary position with double valvular lesion, in which the percutaneous pulmonary valve implant was a successful strategy. Patients with congenital heart disease were chosen, with dysfunctional surgical conduits with stenosis or significant pulmonary insufficiency, with dysfunction and right ventricular dilatation. The standard technique for the implantation of the Melody pulmonary valve was used, without complications during the procedure or one year of follow-up. Percutaneous implantation of the pulmonary valve is a great advance in the management of patients with congenital heart diseases, with favorable results in the short and medium term, allowing the restoration of ventricular function with minimal risk, compared to surgical replacement in selected patients.

[Impact of 3D printing in surgical planning of congenital heart disease]

Introducción

Los defectos cardíacos congénitos constituyen el 30% de todas las anomalías congénitas. La prevalencia es de 8/1,000 recién nacidos vivos, sin predominio de género. Para una planificación quirúrgica óptima es esencial una evaluación precisa de la anatomía en los defectos cardíacos congénitos. Las modalidades de imagen como el ecocardiograma, la angiografía por cateterismo cardíaco, la tomografía computarizada (TC) o la resonancia magnética (RM) se utilizan de forma regular para el diagnóstico de las cardiopatías congénitas. Estos métodos pueden proporcionar reconstrucciones virtuales en reconstrucción volumétrica o 3D, pero no réplicas táctiles reales de la anatomía cardíaca.

Objetivo

Realizar modelos de corazón impresos en 3D con la finalidad de proporcionar réplicas táctiles 3D reales de la anatomía cardíaca para visualizar de forma detallada todas las perspectivas posibles de las estructuras extracardíacas o intracardíacas.

Métodos

Los datos de la imagen se obtuvieron en formato DICOM, se editaron en el paquete de software "3D slicer 4.3" y se exportaron para la impresión en formato de archivo (.stl).

Resultados y conclusiones

Con la impresión 3D se puede evaluar de forma detallada la anatomía intracardíaca y extracardíaca con modelos cardíacos en tiempo real. Esta técnica es de gran utilidad, sobre todo en los defectos cardíacos congénitos complejos, ya que permite hacer una planificación precisa del procedimiento quirúrgico.

Introduction

Congenital heart disease makes up for 30% of all congenital anomalies. The prevalence is 8/1,000 live newborns, without predominance of gender. Imaging methods such as echocardiography, angiography, computed tomography or magnetic resonance imaging must be routinely used in congenital heart disease. The mentioned methods can provide virtual reconstructions in volumetric reconstruction or in three dimensional (3D), but only 3D-printed heart models can provide real 3D tactile replicas of cardiac anatomy.

Objective

To make 3D printed heart models in order to provide real 3D tactile replicas of the cardiac anatomy that allow a detailed visualization from all possible perspectives, either of extracardiac or intracardiac structures.

Methods

This information is useful for surgical decision making, especially in patients with complex cardiac defects. DICOM, edited in a software package “3D slicer 4.3” and exported for printing in file format (.stl).

Results and conclusions

With 3D printing, the intracardiac and extracardiac anatomy can be evaluated in detail with real-scale cardiac models of the patient, avoiding unexpected findings. This technique is very useful especially in complex congenital heart defects, since it allows precise planning of the surgical procedure.

[Correlation between optic nerve sheath diameter and extracorporeal life support time]

INTRODUCTION

The objective of the study was to analyse the correlation between extracorporeal life support (ECLS) and aortic cross-clamp times and optic nerve sheath diameter (ONSD).

PATIENTS AND METHODS

Study in a cohort of patients aged 0 to 15 years that underwent ECLS for cardiac surgery after obtention of signed informed consent. We calculated a sample size of 23 participants. First, we obtained 3 vertical and 3 horizontal measurements of the ONSD for each eye and calculated the mean of both eyes for each measurement to be used in the analysis. The measurements were made at admission and at 6 and 24hours post surgery. We retrieved the ECLS time and the aortic cross-clamp time were from the operative report.

RESULTS

We analysed data for 23 participants, 52.2% female, with a median age of 14 months. The median ECLS time was 60minutes; the median aortic cross-clamp time was 32minutes. The median baseline ONSD was 3.1mm. ONSD values had increased a median of 0.015mm at 6hours post surgery (P=.03). We found a positive correlation between ECLS time and ONSD values (r=0.476, p<,05). The ONSD values returned to baseline by 24hours post surgery. None of the patients developed signs or symptoms of increased intracranial pressure.

CONCLUSION

Our study found a correlation between ECLS time and ONSD at 24hours post surgery. We found variations in the ONSD even in patients without signs or symptoms of increased increased intracranial pressure. Further research is required to identify the factors related to these variations.

Genetics in congenital heart disease. Are we ready for it?

Genetics has rightly acquired an important place in almost all medical disciplines in recent years and this is certainly the case in the field of congenital cardiology. Not only has this led to greater insight into the pathophysiology of congenital heart defects but it also has a beneficial impact on patient management. Integration of clinical genetics in multidisciplinary centers of expertise for CHD is therefore a clear recommendation. Adult and pediatric cardiologists play a crucial role in the process of genetic evaluation of patients and families and should have be familiar with red flags for referral for further clinical genetic elaboration, counseling, and eventual testing. Some basic knowledge is also important for the correct interpretation of genetic testing results. In this review article, we provide a practical overview of what genetic evaluation entails, which type of genetic tests are possible today, and how this can be used in practice for the individual patient.

[Neurological changes and outcomes of paediatric surgery of the aortic arch using selective cerebral perfusion]

INTRODUCTION

The aims of this article are to analyse the neuropsychological changes in the medium-term in children subjected to aortic arch surgery using selective cerebral perfusion (SCP), as well as to detect any modifiable factors in the surgical technique that may contribute to minimising the subsequent neurological involvement.

MATERIAL AND METHODS

Inclusion criteria were established as: aortic arch disease operated on using SCP during the first year of life, between 10 August 2004 and 24 May 2016, biventricular physiology, and gestational age greater than 31 weeks. In the absence of a chromosomal disease, they were classified, from a neurological point of view, using the Rankin score. Children over 4-years of age were subjected to intelligence studies, including attention level, development, and psycho-lingual skills.

RESULTS

The study included a total of 82 patients with a mean age of 1.8 months. The mean SCP flow was 32ml/kg/min. The mean time of SCP was 31minutes. The overall mortality of the series was 14.8%. Neurological dysfunction was observed in 35.9% of patients, and the following were detected as risk factors: surgery in patients less than 10-days-old, duration of SCP greater than 40minutes, and the time required for the cooling down and/or warming-up. Attention deficit was diagnosed in 35.2% of patients greater than 5-years-old.

CONCLUSIONS

Patients operated on using SCP in in the first year of life required a neuropsychological follow-up, and there are modifiable surgical factors that may have an influence on neurological development.

[Recommendations of the Spanish Society of Paediatric Cardiology and Congenital Heart Disease as regards the use of drugs in attention deficit hyperactivity disorder in children and adolescents with a known heart disease, as well as in the general paediatric population: Position statement by the Spanish Paediatric Association]

INTRODUCTION

Approved drugs for attention deficit hyperactivity disorder (ADHD) in Spain are methylphenidate, lisdexamphetamine, atomoxetine and guanfacine. Due to adverse cardiovascular effects, mainly increased blood pressure and heart rate, its use in patients with known or undiagnosed heart disease may be controversial.

OBJECTIVE

To obtain a consensus document from the Spanish Society of Paediatric Cardiology and Congenital Heart Diseases (SECPCC) and experts from other Agencies and Societies as a guide for the paediatric cardiologist and physicians who treat children and adolescents with ADHD.

METHODOLOGY

An analysis was performed on the bibliography and Clinical Practice Guidelines, technical data sheets approved by the Spanish Agency of Medicines and Health Devices, and the Spanish Ministry of Health Guidelines. A Working Group was formed, with a Coordinator, as well as members of the Clinical Cardiology Working Group and Arrhythmia Group of the SECPCC. This Group produced a preliminary document that was reviewed by a group of external experts and a group of internal experts of the SECPCC with a consensus being reached on the final document.

RESULTS

The recommendations of the SECPCC and the group of experts are presented on cardiovascular evaluation prior to treatment in children and adolescents with no known cardiovascular disease and with known cardiovascular disease. The recommendations of the SECPCC and the group of experts are also presented on the use of medications for ADHD in children and adolescents with cardiological symptoms with no evidence of heart disease, congenital heart disease, cardiomyopathy, Marfan syndrome and other aortic diseases, hypertension, and arrhythmias.

Regionalization of congenital heart disease care: A pending goal

Congenital heart diseases (CHDs) are considered the most frequent malformations. In Mexico, every year between 12 and 16 thousand children are born with some type of CHD and it is the second cause of mortality in children under 1 year of age and in children aged between 1 and 4 years. The problem of the care of CHDs is analyzed from a perspective of health policies in the country with an emphasis on regionalizing their care to rationalize the use of available resources and with the aim of serving the largest number of patients and achieve the best clinical results. It emphasizes the need to promote cooperation among the different civil society organizations and institutions to exchange ideas to create consensus and joint projects for a better use of available resources to achieve universal and quality care of children with CHD in all the country.

La regionalización de la atención de cardiopatías congénitas: una meta pendiente

Congenital heart diseases are considered the most frequent malformations. In Mexico every year between 12 and 16 thousand children are born with some type of congenital heart disease and it is the second cause of mortality in children under 1 year of age and in children aged between 1 and 4 years. The problem of the care of congenital heart diseases is analyzed from a perspective of health policies in the country with an emphasis on regionalizing their care in order to rationalize the use of available resources and with the aim of serving the largest number of patients and achieve the best clinical results. It emphasizes the need to promote cooperation among the different civil society organizations and institutions to exchange ideas to create consensus and joint projects for a better use of available resources to achieve universal and quality care of children with congenital heart disease in all the country.

[Congenital heart defects in the Valencian Community 2007-2014: The Population-Based Registry Of Congenital Anomalies]

INTRODUCTION

Congenital heart defects (CHDs) are the most prevalent and severe type of major congenital anomalies (CAs). The objective of this study was to determine the frequency and distribution of CHDs in the Valencian Region from 2007 to 2014, describing common characteristics of the patients and their mothers.

MATERIAL AND METHODS

We retrieved data on CHDs in live births, stillbirths and cases of termination of pregnancy for fetal anomaly between 2007 and 2014 (codes Q20-Q26 in the 10th Revision of the International Classification of Diseases-British Paediatric Association, ICD10-BPA) from the population-based Registry of congenital anomalies of the Valencian Region. We calculated the prevalence per every 10,000 births of CHDs overall and by subtype, analysed temporal trends and the geographic distribution of cases, and documented the presence of associated noncardiac malformations.

RESULTS

We identified 3,671 cases of CHD, corresponding to 38.6% of all CAs. The prevalence was 91.1/10,000 (IC 95%: 88.1-94.0) with a predominance of septal defects, chiefly atrial septal defect (48.5/10,000; IC 95%: 46.4-50.6) and ventricular septal defect (36.1/10,000; IC 95%: 34.3-38.0). We found the highest prevalence in the province of Castellon (137.8/10,000; IC 95%: 127.5-148.1). The sex distribution was 47.3% male and 44.3% female. Of all cases, 90.9% corresponded to live births and 65.6% were diagnosed at birth. The most frequent associated extracardiac malformations were musculoskeletal, and 19.2% of patients had syndromes. The most frequent maternal diseases were diabetes mellitus, hypothyroidism and urinary tract infections.

CONCLUSIONS

The prevalence of CHD and atrial septal defects was higher compared to European data, while the prevalence of ventricular septal defects was similar. Musculoskeletal malformations were the noncardiac CAs most frequently associated with CHDs.

[Las cardiopatías congénitas en el 2018]

We present an update of the most relevant advances of three-dimensional echocardiography for the diagnosis of congenital heart diseases. The evolution of its treatment is analyzed, showing the results obtained in recent years. The functional and structural changes experienced in women with congenital heart disease during pregnancy are discussed, as well as the main health risks and the importance of teamwork in healthcare to treat these patients. Finally, we provide a review on the current situation in Mexico and outline some improvement recommendations.

Factors associated with early extubation of patients after corrective tetralogy of Fallot

OBJECTIVE

To assess surgical management and postoperative results associated with early extubation in patients undergoing tetralogy of Fallot corrective surgery at a public hospital in Argentina.

METHODS

A retrospective review was made from clinical records from patients who underwent corrective surgery for tetralogy of Fallot. A total of 38 clinical records that met the inclusion criteria for the retrospective review were included in the analysis.

RESULTS

16% were extubated early. Milrinone was the only drug that showed differences in patients who were extubated early (p=0.01). Extracorporeal circulation time, aortic clamping time, transfusion with cryoprecipitates, saturation of oxygen pressure, and haematocrit at the end of the surgical procedure showed no differences (p>.05). In the postoperative period, the ICU stay was shorter for the patients who were extubated early (p=0.0007), but there were no differences in the total hospital stay (p=0.26).

CONCLUSIONS

Early extubation in the institution, although found to be low frequency, has proved as a safe and effective alternative to shorten these patients' stay in ICU.

Changes in Adrenoceptor and GRK Expression in Patients With Chronic Pulmonary Regurgitation

INTRODUCTION AND OBJECTIVES

Pulmonary regurgitation (PR) is a frequent complication after repair of congenital heart disease. Lymphocyte expression of adrenoceptors (β1 and β2) and kinases (GRK2, GRK3, and GRK5) reflects the neurohumoral changes that occur in heart failure (HF). The main objective of this study was to describe the gene expression of these molecules in circulating lymphocytes in patients with severe PR.

METHODS

A prospective study was conducted to analyze lymphocyte expression of these molecules in patients with severe PR and compare it with expression in healthy controls and patients with advanced HF.

RESULTS

We studied 35 patients with severe PR, 22 healthy controls, and 13 patients with HF. Multiple comparisons analysis showed that β2-adrenoceptor gene expression levels were higher in the control group than in patients in the PR and HF groups and that expression in the latter 2 groups was similar (748.49 [rank 1703.87] vs 402.80 [rank 1210.81] vs 287.46 [rank 685.69] P = .001). Similar findings were obtained in gene expression of GRK2 (760.89 [rank 1169.46] vs 445.17 [rank 1190.69] vs 284.09 [rank 585.27] P < .001). There were no differences in expression levels of these molecules according to clinical variables in patients with PR.

CONCLUSIONS

The gene expression pattern of GRK2 and β2-adrenoceptor as molecular markers of cardiac dysfunction was altered in patients with severe PR compared with controls and was similar to expression in patients with advanced HF.

Socio-demographic and preconception risk factors in parents of children suffering from congenital cardiopathy

OBJECTIVE

To identify the preconception risk factors in parents of children suffering from congenital cardiopathy.

METHOD

A cross-sectional descriptive study, which included parents of children suffering from cardiopathy, attended at consultations in a not-for-profit organization, in order to be diagnosed and referred for heart surgery or to be assessed in postoperative cardiac monitoring. The sample population included 500 people who responded to a survey for the identification of socio-demographic and preconception risk factors.

RESULTS

Couples were found with up to 3 cardiac children. Parents with 2 or more children suffering from cardiopathy were classified in the majority as belonging to the middle socioeconomic level and not owning their own house. An association with the number of children with cardiopathy, the educational level of their parents (P=.013), their home area (P=.041) and type of accommodation (P=.045) was found. Regarding the preconception risk factors, there was evidence of statistically significant associations among the number of children with cardiopathy and their exposure to fertilizers (P=.024), their exposure to fuels (P=.025), the use of antihypertensive medication (P=.37), and alcohol consumption (P=.042) and cocaine use (P=.039) by their parents.

CONCLUSIONS

The population of parents with a greater number of children suffering from cardiopathy were characterized as having socioeconomic and educational constraints. The preconception risk factors which show an association with the number of children suffering from cardiopathy were characterized as physical and/or chemical environmental risk factors and the consumption of certain psychoactive substances and medication by their parents. It is necessary to analyze each risk factor separately, taking into account the different types of cardiopathy.

Impact of Percutaneous Pulmonary Valve Implantation on the Timing of Reintervention for Right Ventricular Outflow Tract Dysfunction

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect. Early surgical repair has dramatically improved the outcome of this condition. However, despite the success of contemporary approaches with early complete repair, these are far from being curative and late complications are frequent. The most common complication is right ventricle outflow tract (RVOT) dysfunction, affecting most patients in the form of pulmonary regurgitation, pulmonary stenosis, or both, and can lead to development of symptoms of exercise intolerance, arrhythmias, and sudden cardiac death. Optimal timing of restoration of RVOT functionality in asymptomatic patients with RVOT dysfunction after TOF repair is still a matter of debate. Percutaneous pulmonary valve implantation, introduced almost 2 decades ago, has become a major game-changer in the treatment of RVOT dysfunction. In this article we review the pathophysiology, the current indications, and treatment options for RVOT dysfunction in patients after TOF repair with a focus on the role of percutaneous pulmonary valve implantation in the therapeutic approach to these patients.

[Heart murmur in children less than 2 years-old: looking for a safe and effective referral strategy]

INTRODUCTION

Current guidelines in Spain recommend performing transthoracic echocardiography (TTE) in all children under 2 years of age with a heart murmur. In 2014, the American Paediatric Association published the first appropriate use criteria (AUC) for outpatient paediatric transthoracic echocardiography (TTE) to promote its cost-efficient use. The aim of this article is to analyse the AUC and other clinical factors as predictors of congenital heart disease (CHD) in children less than 2 years of age with a heart murmur, and to develop a safe and efficient referral strategy.

PATIENTS AND METHOD

Case-control study conducted with children less than 2 years of age, referred from Paediatric Primary Care to Paediatric Cardiology during a 4-year study. A predictive model for CHD was determined using multivariate analysis.

RESULTS

A total of 688 patients were included, with 129 (19%) cases of CHD. An age less than 3 months (adjusted odds ratio [ORa] 3.8 [1.5-8.4], p=.030) and fulfilling AUC (ORa 16.3 [9.4-28.3], p<.001) were predictors of CHD. Concurrent infection (ORa 0.6 [0.2-0.8], p<.001) and a negative neonatal screening with pulse oximetry (ORa 0.1 [0.05-0.4], p=.001) decreased the risk of CHD. The referral strategy that included these criteria had a 98% sensitivity, 39% specificity, and positive and negative predictive values of 27% and 99%, respectively. It could not diagnose 2% of CHD (all mild), and showed a 32% TTE reduction rate compared to our current strategy.

CONCLUSION

To refer children less than 3 months old, fulfilling AUC, without a concurrent infection, or without negative neonatal pulse oximetry screening, is a safe and efficient strategy for the management of heart murmur in children under 2 years of age.

[Overweight and obesity in children treated for congenital heart disease]

INTRODUCTION

The negative impact of overweight and obesity is potentially greater in children affected by a congenital heart disease (CHD). The aim of this study is to calculate the proportion of overweight and obesity in children who underwent an intervention for CHD, and to investigate systolic arterial hypertension as a possible early cardiovascular complication.

PATIENTS AND METHODS

A retrospective study was conducted on patients aged 6-17 years treated for CHD, and healthy control subjects, followed-up in a Paediatric Cardiology Clinic. Body mass index percentiles were calculated according to the criteria of WHO. A review was performed on the anthropometric and clinical data, as well as the systolic blood pressure (SBP).

RESULTS

A total of 440 patients were included, of which 220 had CHD. The proportion of combined obesity and overweight (body mass index percentile ≥85) was 36.4% (37.3% in healthy subjects and 35.4% in patients with CHD, P=.738). A higher prevalence of obesity (body mass index percentile ≥97) was found in CHD patients (22.7%) compared to 15.5% in healthy subjects (P=.015). SBP percentiles were higher in overweight compared to normal-weight patients (P < .001). The prevalence of SBP readings ≥ the 95th percentile was greater in overweight than in normal weight CHD patients (29.5% versus 7.7%, P < .001) and also in the overweight healthy controls compared to those of normal weight (12.2% versus 0.7%, P < .001).

CONCLUSIONS

The proportion of obesity is high in children treated for CHD and it is associated with elevated SBP levels. The risk of long-term complications needs to be reduced by means of prevention and treatment of obesity in this vulnerable population.

[Incidence and evolution of congenital heart disease in Spain from 2003 until 2012]

INTRODUCTION AND OBJECTIVES

Congenital heart disease (CHD) represents the most common congenital malformation. The objective of this study was to analyse the incidence of CHD in Spain, and it is the first nationwide study so far.

METHODS

A retrospective observational study was performed in order to evaluate the incidence of CHD in Spain. The administrative database (minimum basic data set) from 2003 to 2012 was analysed in children less than one year old admitted to hospital with codes of CHD (International Classification of Diseases, 9th Revision, clinical modification). Cumulative incidence, Incidence relative risk, and standardised incidence ratio were calculated to study geographic variations.

RESULTS

There were 64,831 infants with CHD among the 4,766,325 births analysed during the period studied, with an incidence of 13.6‰. The incidence excluding atrial septal defect was 7.29 ‰.The most frequent CHD were atrial septal defect (6.31‰), ventricular septal defect (3.48‰), patent ductus arteriosus (2.71‰), coarctation of the aorta (0.55‰), pulmonary stenosis (0.50‰), transposition of the great arteries (0.49‰), atrioventricular septal defect (0.45‰), and tetralogy of Fallot (0.41‰). Castilla and Leon, together with Extremadura, showed the highest risks for severe and very severe CHD, while Madrid and Cantabria showed the lowest.

CONCLUSIONS

An increase of mild CHD was observed during the period analysed. This could have been influenced by improvements in diagnostic techniques, extended use of echocardiography, and the International Classification of Diseases, 9th Revision, clinical modification coding system, and to a decrease in very severe CHD, which is less influenced by external factors. Significant geographical differences were found in the incidence of severe and very severe CHD.

Pediatric Catheter Ablation: Characteristics and Results of a Series in a Tertiary Referral Hospital

INTRODUCTION AND OBJECTIVES

Catheter ablation has become the treatment of choice in an increasing number of arrhythmias in children and adolescents. There is still limited evidence of its use at a national level in Spain. The aim was to describe the characteristics and results of a modern monocentric series form a referral tertiary care centre.

METHODS

Retrospective register of invasive procedures between 2004 and 2016 performed in patients under 17 years and recorded clinical characteristic, ablation methodology and acute and chronic results of the procedure.

RESULTS

A total of 291 procedures in 224 patients were included. Median age was 12.2 years, 60% male. Overall, 46% patients were referred from other autonomous communities. The most frequent substrates were accessory pathways (AP) (70.2%,>50% septal AP localization) and atrioventricular nodal reentrant tachycardia (AVNRT) (15.8%). Congenital and acquired heart disease was frequent (16.8%). Cryoablation was used in 35.5% of the cases. Overall acute success of the primary procedure was 93.5% (AP 93.8%; AVNRT 100%). Redo procedures after recurrence were performed in 18.9% of all substrates, with a long-term cumulative efficacy of 98.4% (AP 99.3%; AVNRT 100%). One (0.37%) serious complication occurred, a case of complete atrioventricular block.

CONCLUSIONS

Our study replicated previous international reports of high success rates with scarce complications in a high complexity series, confirming the safety and efficacy of pediatric catheter ablation in our environment performed at highly experienced referral centers.

[Congenital heart disease mortality in Spain during a 10 year period (2003-2012)]

INTRODUCTION AND OBJECTIVES

Congenital heart disease is a major cause of infant mortality in developed countries. In Spain, there are no publications at national level on mortality due to congenital heart disease. The aim of this study is to analyse mortality in infants with congenital heart disease, lethality of different types of congenital heart disease, and their variation over a ten-year period.

METHODS

A retrospective observational study was performed to evaluate mortality rate of children under one year old with congenital heart disease, using the minimum basic data set, from 2003 to 2012. Mortality rate and relative risk of mortality were estimated by Poisson regression.

RESULTS

There were 2,970 (4.58%) infant deaths in a population of 64,831 patients with congenital heart disease, with 73.8% of deaths occurring during first week of life. Infant mortality rate in patients with congenital heart disease was 6.23 per 10,000 live births, and remained constant during the ten-year period of the study, representing 18% of total infant mortality rate in Spain. The congenital heart diseases with highest mortality rates were hypoplastic left heart syndrome (41.4%), interruption of aortic arch (20%), and total anomalous pulmonary drainage (16.8%). Atrial septal defect (1%) and pulmonary stenosis (1.1%) showed the lowest mortality rate.

CONCLUSIONS

Congenital heart disease was a major cause of infant mortality with no variations during the study period. The proportion of infants who died in our study was similar to other similar countries. In spite of current medical advances, some forms of congenital heart disease show very high mortality rates.

Three-dimensional Printed Cardiac Models: Applications in the Field of Medical Education, Cardiovascular Surgery, and Structural Heart Interventions

In recent years, three-dimensional (3D) printed models have been incorporated into cardiology because of their potential usefulness in enhancing understanding of congenital heart disease, surgical planning, and simulation of structural percutaneous interventions. This review provides an introduction to 3D printing technology and identifies the elements needed to construct a 3D model: the types of imaging modalities that can be used, their minimum quality requirements, and the kinds of 3D printers available. The review also assesses the usefulness of 3D printed models in medical education, specialist physician training, and patient communication. We also review the most recent applications of 3D models in surgical planning and simulation of percutaneous structural heart interventions. Finally, the current limitations of 3D printing and its future directions are discussed to explore potential new applications in this exciting medical field.

[Post-surgical morbidity in paediatric patients undergoing surgery for congenital heart disease in the UMAE of Yucatan, Mexico]

OBJECTIVE

To describe the clinical course of paediatric patients undergoing surgery for congenital heart disease in UMAE of Yucatan.

METHODS

Descriptive review was performed on the records of paediatric patients undergoing surgery for congenital heart disease from 1 November 2011 to 30 November 2013.

RESULTS

The most frequent heart diseases were persistent ductus arteriosus (37.6%) and transposition of the great vessels. The median intensive care stay was 3 days. Mortality was 11.76%, with septic shock (44.4%) in most cases. The most frequent complications were sepsis (5.9%), low cardiac output syndrome (4.7%), cardiac arrest, and AV block and ventricular tachycardia (2.4% each). There was a moderate positive correlation between surgical complications and survival or death.

CONCLUSIONS

The number of surgical patients is lower compared to reference centres for cardiovascular surgery. There is a marked tendency to perform corrective and palliative surgeries in specific disease in patients with added risk or 'bad' cardiac anatomy that prevent full correction at the first attempt. Prospective epidemiological and clinical studies should be conducted to understand the behaviour of congenital heart diseases treated in the region.

[Comparative results of Fontan surgery in patients with and without hypoplastic left heart syndrome]

INTRODUCTION

During the last few years, numerous patients with univentricular heart disease have been treated surgically with total cavopulmonary anastomosis according to a staged surgery protocol in our institution.

OBJECTIVE

To evaluate the perioperative outcomes and survival of patients with hypoplastic left heart syndrome (HLHS) after the Fontan procedure and compare them with other types of univentricular heart disease.

PATIENTS AND METHOD

A total of 102 patients underwent a Fontan procedure between April 1996 and March 2014, 25 with HLHS (group I), and 77 patients with other types of univentricular heart disease (group II). Groups survival, demographics, hemodinamic studies, morbimortality, mechanical ventilation, surgical drains, post-operative stay, isotopes score, pacemaker use, and requiriment of Fontan takedown were analyzed.

RESULTS

Intraoperative mortality was 4% (n=1) for group I, and 7.8% (n=6) for group II (P=.451). A difference was only found in hospital length of stay (LOS), being 17 days (6-47) for group I and 12 days (5-103) for group II (P=.017). Mean follow-up was 4.24±2.08 years for group I, and 8.7±4.67 for group II. Survival rate at 8 years for both groups was 88%, and 81% at 10 years for group II.

CONCLUSIONS

The Fontan procedure had similar mortality, but longer LOS, in patients with HLHS compared to those with another types of single ventricle anatomy. Long term survival was comparable between both groups.

[Infective endocarditis in adult patients with congenital heart disease. Experience from a reference centre]

INTRODUCTION

A growing number of patients with congenital heart disease (CHD) will reach adulthood. Infective endocarditis (IE) is a major complication in this population. The aim of this study was to describe the features of IE in adults with CHD treated in a reference centre.

METHODS

A retrospective review was performed on a cohort of patients over 16 years of age with CHD who presented with IE (defined by the modified Duke criteria) between 1996 and 2014. Only the first episode from each patient was considered for the descriptive analysis.

RESULTS

IE was observed in 27 patients. The median age at diagnosis of IE was 27.7 years, and 63% were male. Comorbidity was low (median Charlson index was 0). IE was mostly community-acquired (78%). The most frequent CHD were ventricular septal defect (33%). A repair was performed in 48% of patients, and 19% received palliative treatment. Forty-one percent of patients had some type of prosthesis. A residual defect was observed in 81%. The IE was detected in the right side of 44% of the patients. The most frequent aetiological agents were viridans group streptococci (41%) and Staphylococcus epidermidis (30%). Surgery was required to treat IE in 37% of patients. There were five re-infections and three relapses. Two patients died, both as a result of recurrence.

CONCLUSIONS

IE in adults with CHD occurred in young patients, and almost all of them carried some prosthetic material or a residual defect. The IE is frequently right-sided. Although surgical treatment was required in many cases, mortality was low, except in the case of relapses.

[Assessment of exercise capacity in congenital heart disease]

For many years, the treatment of congenital heart diseases has been a field in which, based on the seriousness of these conditions, treatment options were viewed with the greatest deference. This has conditioned, in many cases, the interventions to be undertaken in each. In this sense, exercise was thought to have a negative impact and thus the practise of almost any physical activity was limited. Although there has recently been a change in the paradigm with respect to exercise, this idea continues to hold sway. For many cardiopathies, the information obtained through a stress test is essential in order to implement and supervise an exercise program. The aim of this study is to analyze the parameters within the stress test which allow for an adequate stratification of the risk to subjects with congenital heart diseases who undertake exercise, as well as their values in accordance with the type of pathology, the gravity of such, and the age of the patients. Furthermore, these parameters will be analyzed for both their survival markers and the protocols that can best be adjusted for patients with these characteristic.

[Hypoplastic left heart syndrome: 10 year experience with staged surgical management]

Hypoplastic left heart syndrome (HLHS) is a lethal congenital heart disease in 95% of non-treated patients. Surgical staging is the main form of treatment, consisting of a 3-stage approach, beginning with the Norwood operation. Long term survival of treated patients is unknown in our country.

OBJECTIVES

1) To review our experience in the management of all patients seen with HLHS between January 2000 and June 2012. 2) Identify risk factors for mortality.

PATIENTS AND METHOD

Retrospective analysis of a single institution experience with a cohort of patients with HLHS. Clinical, surgical, and follow-up records were reviewed.

RESULTS

Of the 76 patients with HLHS, 9 had a restrictive atrial septal defect (ASD), and 8 had an ascending aorta ≤2mm. Of the 65 out of 76 patients that were treated, 77% had a Norwood operation with pulmonary blood flow supplied by a right ventricle to pulmonary artery conduit, 17% had a Norwood with a Blalock-Taussig shunt, and 6% other surgical procedure. Surgical mortality at the first stage was 23%, and for Norwood operation 21.3%. For the period between 2000-2005, surgical mortality at the first stage was 36%, and between 2005-2010, 15% (P=.05). Actuarial survival was 64% at one year, and 57% at 5years. Using a multivariate analysis, a restrictive ASD and a diminutive aorta were high risk factors for mortality.

CONCLUSIONS

Our immediate and long term outcome for staged surgical management of HLHS is similar to that reported by large centres. There is an improvement in surgical mortality in the second half of our experience. Risk factors for mortality are also identified.

[15 years of minimally invasive paediatric cardiac surgery; development and trends]

INTRODUCTION

The minimally invasive approach is seldom reported in paediatric cardiac surgery. Teams gathering experience are scarce, with programs focused on simple cases. The experience is presented on a series of over 200 cases operated on in the past 15 years.

MATERIAL AND METHODS

A sub-mammary approach program was started in 2000, which was gradually extended to include more complex and younger patients. The axillary incision was adopted in 2009, following the same steps. In 2013, the mini-sternotomy incision was introduced, increasing our armamentarium. From July 2000 until December 2014, 203 patients were operated on. The sub-mammary approach was used in 102 cases, axillary in 50 patients, mini-sternotomy in 44, postero-lateral thoracotomy in 4 cases, and upper mini-sternotomy in 3.

RESULTS

By diagnosis, ostium secundum atrial septal defect was the most common (128), followed by sinus venosus (20), ventricular septal defect (20), ostium primum (16), and others (19). One patient was converted to sternotomy. No neurological events were detected. The mean age was 7.8/3.7 and 1.8 years, and the mean weight was 28.1/16.1 and 9.4 Kg. in the sub-mammary, axillary and mini-sternotomy approaches, respectively. The aesthetic results were excellent.

CONCLUSIONS

Based on our 15 years of experience, minimally invasive surgery is safe and yields excellent cosmetic results. The gradual introduction of alternative approaches (sub-mammary, axillary, mini-sternotomy) allowed us to set-up guidelines and learning curves. The wide range of incisions enables the most appropriate one to be selected depending on age/weight and cardiac condition.

What radiologists need to know about the pulmonary-systemic flow ratio (Qp/Qs): what it is, how to calculate it, and what it is for

Cardiac magnetic resonance imaging (cMRI) provides abundant morphological and functional information in the study of congenital heart disease. The functional information includes pulmonary output and systemic output; the ratio between these two (Qp/Qs) is the shunt fraction. After birth, in normal conditions the pulmonary output is practically identical to the systemic output, so Qp/Qs = 1. In patients with « shunts » between the systemic and pulmonary circulations, the ratio changes, and the interpretation of these findings varies in function of the location of the shunt (intracardiac or extracardiac) and of the associated structural or postsurgical changes. We review the concept of Qp/Qs; the methods to calculate it, with special emphasis on cMRI; and the meaning of the results obtained. We place special emphasis on the relevance of these findings depending on the underlying disease and the treatment the patient has undergone.

[Pulmonary hypertension associated with congenital heart disease and Eisenmenger syndrome]

Pulmonary arterial hypertension is a common complication of congenital heart disease (CHD). Congenital cardiopathies are the most frequent congenital malformations. The prevalence in our country remains unknown, based on birthrate, it is calculated that 12,000 to 16,000 infants in our country have some cardiac malformation. In patients with an uncorrected left-to-right shunt, increased pulmonary pressure leads to vascular remodeling and endothelial dysfunction secondary to an imbalance in vasoactive mediators which promotes vasoconstriction, inflammation, thrombosis, cell proliferation, impaired apotosis and fibrosis. The progressive rise in pulmonary vascular resistance and increased pressures in the right heart provocated reversal of the shunt may arise with the development of Eisenmenger' syndrome the most advanced form de Pulmonary arterial hypertension associated with congenital heart disease. The prevalence of Pulmonary arterial hypertension associated with CHD has fallen in developed countries in recent years that is not yet achieved in developing countries therefore diagnosed late as lack of hospital infrastructure and human resources for the care of patients with CHD. With the development of targeted medical treatments for pulmonary arterial hypertension, the concept of a combined medical and interventional/surgical approach for patients with Pulmonary arterial hypertension associated with CHD is a reality. We need to know the pathophysiological factors involved as well as a careful evaluation to determine the best therapeutic strategy.

Usefulness of 64-detector computed tomography in the diagnosis and management of patients with congenital heart disease

INTRODUCTION AND OBJECTIVES

Although congenital heart defects are the most common major congenital abnormalities, the associated mortality has been decreasing due to improvements in their diagnosis and treatment. We assessed the usefulness of 64-multidetector computed tomography in the diagnosis and management of these patients.

METHODS

This 5-year observational, analytical, retrospective, cohort study included a total of 222 tomographic studies of patients with congenital heart disease. Computed tomography scans were read twice and medical records were reviewed. We assessed the complexity of the disease, patient, and radiological technique, and evaluated the contribution of new data in relation to clinical suspicion and diagnostic change. A confidence interval was set at 95% and a P value of<.05 was used as the cutoff for statistical significance.

RESULTS

In 35.1% of patients, the treatment procedure was performed after computed tomography without other tests. Additional diagnostic catheterization was performed in 12.5% of patients. There were new findings in 77% of patients (82.9% with complex disease), which prompted a change in patient management in 35.6%. All unexpected reports described new findings. No significant differences were found by age, sex, study period, urgency of the test order, patient complexity, or difficulty of the technique.

CONCLUSIONS

Use of 64-detector computed tomography yields good diagnostic performance in congenital heart disease, prompts changes in management in more than one-third of patients, and reveals new findings in relation to the presumed diagnosis in 77% of patients.

[Percutaneous closure of atrial septal defects with the Amplatzer® device: 15 years of experience]

INTRODUCTION

Percutaneous closure of atrial septal defects is an alternative to surgical treatment.

OBJECTIVES

We report the results of percutaneous closure of atrial septal defects with the Amplatzer(®) device.

METHOD

We include patients taken to the catheterization laboratory from September 1997 to December 2011.

RESULTS

We proceeded with defect closure in 721 patients and in 85 the defect was considered not suitable for closure. The stretched diameter of the defect was 23±6.7mm (limits, 5-42). All devices were positioned successfully. In 15 cases (2.1%) the device was changed due to instability and in 6 (0.8%) the device embolized within the first 24h, 4 were retrieved and repositioned (final success with intention to treat 719/806-89.2%). Immediate control showed complete closure in 247 patients (34.3%), leak through the device in 395 (54.9%), mild residual leak in 75 (10.4%) and moderate in 2 (0.3%). We have follow-up in 626 patients (87.1%) for 33±27.5 months, with headache in 54 (8.6%), new supraventricular arrhythmia in 10 (1.6%), puncture site complications in 4 (0.6%), and stroke in one (0.1%).

CONCLUSION

The design of the Amplatzer(®) device allows effective closure of atrial septal defects with a simple technique and patient safety.

[Risk factors for surgery of congenital heart disease in adults: twenty-two years of experience. Who should operate them?]

OBJECTIVE

To assess the association between mortality in surgery of congenital heart disease in adults, and factors related to patients and operations.

METHOD

Descriptive study of operations performed by specialized surgeons in congenital heart surgery (238), adult acquired surgery (117), and specialty residents (108). The association of mortality with surgical risk and complexity, specialization of surgeon, cardiopulmonary by-pass and aortic cross clamping was assessed fitting logistic regression models.

RESULTS

A total of 463 operations were included (442 with cardiopulmonary by-pass) in the study performed between 1991 and 2012. Median age at surgery: 34; 52.8% were women. First surgery: 295, reoperation: 168. Median score of Aristotle was 6.8, with significantly higher complexity since 2001, after restructuring the Unit. Overall hospital mortality was 3.9%. Mortality was significantly associated to number of previous surgeries (OR: 5.02; 95%CI: 1.44-17.52), operations by acquired heart disease surgeons (OR: 3.53; 95%CI: 1.14-10.98), higher Aristotle (OR: 1,64; 95%CI: 1.18-2.29), and high cardiopulmonary by-pass time (OR: 1.13; 95%CI: 1.07-1.19).

CONCLUSIONS

Surgery of congenital heart disease in adults has been performed with low mortality. High complexity interventions, prolonged cardiopulmonary by-pass times and multiple reoperations were associated to higher mortality. Participation of cardiac surgeons specialized in congenital heart disease is associated with better outcomes.

2013 update on congenital heart disease, clinical cardiology, heart failure, and heart transplant

This article presents the most relevant developments in 2013 in 3 key areas of cardiology: congenital heart disease, clinical cardiology, and heart failure and transplant. Within the area of congenital heart disease, we reviewed contributions related to sudden death in adult congenital heart disease, the importance of specific echocardiographic parameters in assessing the systemic right ventricle, problems in patients with repaired tetralogy of Fallot and indication for pulmonary valve replacement, and confirmation of the role of specific factors in the selection of candidates for Fontan surgery. The most recent publications in clinical cardiology include a study by a European working group on correct diagnostic work-up in cardiomyopathies, studies on the cost-effectiveness of percutaneous aortic valve implantation, a consensus document on the management of type B aortic dissection, and guidelines on aortic valve and ascending aortic disease. The most noteworthy developments in heart failure and transplantation include new American guidelines on heart failure, therapeutic advances in acute heart failure (serelaxin), the management of comorbidities such as iron deficiency, risk assessment using new biomarkers, and advances in ventricular assist devices.

[Prenatal screening of congenital heart defects in population at low risk of congenital defects. A reality today]

INTRODUCTION

We propose to demonstrate that it is possible to implement a valid (diagnostic sensitivity for major cardiac malformations 90%), and universal (applied to over 90% of pregnant women), prenatal screening method for congenital heart defects.

MATERIALS AND METHODS

Prospective study. A total of 12478 pregnant women were evaluated between January 2008 and December 2010. Congenital heart diseases were screened using fetal extended basic echocardiography (cardiac ultrasound).

RESULTS

The prevalence of birth defects in general and congenital heart disease was 2.5% (2.2-2.7%) and 0.9% (0.7-1%) respectively. Congenital heart disease had a higher rate of association with other structural abnormalities with 11.5% (5.6-17.4%), 21% for major congenital heart disease (9.9-32%), and chromosomal abnormalities of 15.9% (9.1-22.7%), with 32.6% for major congenital heart disease (19.8-45.3%). A fetal cardiac ultrasound assessment was performed on 99.2% of pregnant women. The fetal echocardiography is useful for the diagnosis of congenital heart disease in general, and major congenital heart disease, with a sensitivity of 42.8% (33.5-52.5%) and 90.4% (78.9-96.8%), respectively, and a specificity for both of 99.9% (99.8-99.9%).

CONCLUSIONS

It is possible to perform a valid prenatal and universal screening of major congenital heart disease.

Long-term results of percutaneous balloon valvuloplasty in pulmonary valve stenosis in the pediatric population

INTRODUCTION AND OBJECTIVES

Percutaneous pulmonary valvuloplasty is the preferred interventional procedure for pulmonary valve stenosis. The aim of this study was to evaluate the effectiveness of this technique, assess the factors leading to its success, and determine the long-term results in the pediatric population.

METHODS

The study included 53 patients with pulmonary valve stenosis undergoing percutaneous balloon valvuloplasty between December 1985 and December 2000. Right ventricular size and functional echocardiographic parameters, such as pulmonary regurgitation and residual transvalvular gradient, were assessed during long-term follow-up.

RESULTS

Peak-to-peak transvalvular gradient decreased from 74 mmHg [interquartile range, 65-100 mmHg] to 20 mmHg [interquartile range, 14-34 mmHg]. The procedure was unsuccessful in 2 patients (3.77%). The immediate success rate was 73.58%. Follow-up ranged from 10 years to 24 years (median, 15 years). During follow-up, all patients developed late pulmonary regurgitation which was assessed as grade II in 58.4% and grade III in 31.2%. There was only 1 case of long-term restenosis (2.1%). Severe right ventricular dilatation was observed in 27.1% of the patients. None of the patients developed significant right ventricular dysfunction. Pulmonary valve replacement was not required in any of the patients.

CONCLUSIONS

Percutaneous balloon valvuloplasty is an effective technique in the treatment of pulmonary valve stenosis with good long-term results.

[Migration of a stent implanted in the pulmonary artery of a patient with tetralogy of Fallot]

Tetralogy of Fallot is a congenital heart disease that accounts for 11-13% of the congenital cardiomyopathies. Stenosis and hyperplasia of the pulmonary arteries occur in a high proportion of them as this disease causes a native stenosis of the pulmonary branch, which can be surgically repaired with a stent. The use of balloon expandable intravascular stents is an alternative technique to further surgery in patients with congenital heart diseases. However, despite the gradual increase in their use, the limited number of procedures, combined with the wide anatomical variability and different characteristics of these patients, even in expert hands, stent implants are associated with a not inconsiderable incidence of complications. These are not always obvious and often require performing surgery in patients who have already had multiple interventions, thus increasing the complexity and the risk.

[Temporal variation and geographical distribution: congenital heart defects in the Comunitat Valenciana]

OBJECTIVES

The objective of this study is to estimate the prevalence of congenital heart defects (CHD) in the Comunitat Valenciana (CV) in children less than one year old and identify whether there are temporal and geographic variations within this prevalence.

METHODS

The minimum basic data set from hospital discharge reports was used to select patients, who were born between 1999-2008, were less than one year old, and who lived in the CV with at least one hospital admission in which the primary diagnosis and/or any of the events were coded as CHD (codes 745-747 of the International Classification of Diseases 9th Revision Clinical Modification). The first hospital discharge report with CHD was selected, using the health card number to detect duplication. The prevalence and 95% confidence intervals were calculated, and the prevalence ratio (PR) and smoothed PR was obtained for each municipality to identify geographic patterns.

RESULTS

In the period 1999-2008 there were 6.377 patients younger than one year with some CHD, representing the 43.2% of cases of congenital anomalies. The prevalence was 134.3 per 10.000 live births (95% CI: 131.1-137.6). There was a significant increase in the prevalence, from 115.8 in the 1999-2003 period to 149.5 in the 2004-2008 period. A higher risk was identified in the north of the CV, and in some municipalities of the province of Alicante, in the south.

CONCLUSIONS

The observed increase in CHD agrees with the findings in other countries and it can be explained, at least in part, by improved diagnostic techniques. The geographic pattern identified requires a more detailed analysis that could explain the geographic variations found.