Screening for hypertrophic cardiomyopathy

Cardiac syncope in pediatric patients

OBJECTIVE

To assess the epidemiology of cardiac syncope in children and evaluate the guidelines on its management.

MATERIAL AND METHODS

We analyzed the etiology to syncope and diagnostic workup in consecutive pediatric patients presenting with syncope in our emergency departments or cardiac outpatient clinics between 1997 and 2005, and who were subsequently diagnosed as having cardiac syncope.

RESULTS

A primary cardiac cause was identified in 11 syncopal patients presenting to the emergency room and 14 patients to the cardiac clinic: supraventricular tachyarrhythmia in 9, ventricular tachyarrhythmia in 10, pacemaker dysfunction in 2, and isolated cases of sick sinus syndrome, hypoxic spell, hypertrophic cardiomyopathy, and primary pulmonary hypertension. Some elements suggested potential cardiac disease as a cause of syncope in all cases. The resting electrocardiogram and the echocardiogram were interpreted as positive and relevant to the diagnosis in 17 and 3 patients, respectively. Exercise electrocardiogram and Holter recording provided diagnostic information previously not seen on the resting electrocardiogram in six and three patients, respectively. Three children have died and one child has neurological sequelae following resuscitation.

CONCLUSION

Our data support the premise that careful history taking with special focus on the events leading up to syncope, as well as a complete physical examination, can guide practitioners in discerning which syncopal children need further cardiac investigations.

Cardiac transplantation for hypertrophic cardiomyopathy: a valid therapeutic option

BACKGROUND

Hypertrophic cardiomyopathy is a rare indication for cardiac transplantation, with only anecdotal reports in the literature. Transplantation has been proposed to patients with hypertrophic cardiomyopathy who remained symptomatic despite optimal medical treatment or who progressed to congestive heart failure, and when conventional surgical correction was not or was no longer possible. In this report, we analyze the clinical results of cardiac transplantation in these patients.

METHODS

We retrospectively reviewed complete clinical data and prospectively gathered complete follow-up data for 14 patients who underwent orthotopic cardiac transplantation for hypertrophic cardiomyopathy at the Montreal Heart Institute and Ste-Justine Hospital between 1984 and 2001.

RESULTS

Ten male (71.4%, 5 adults and 5 children) and 4 female (28.6%, 2 adults and 2 children) patients underwent heart transplantation for hypertrophic cardiomyopathy. The median age of the recipients in the pediatric group was 13 years (range, 6-16) and was 40 years (range, 22-46) in the adult group. Median duration of follow-up was 9.5 years (mean, 8.8 +/- 4.8 years; range, 1-18) and was 100% complete. We found no operative mortality and found 2 late deaths related to coronary graft atherosclerosis. Long-term survival at 5, 10, and 15 years was 100%, 85%, and 64%, respectively. Freedom from acute rejection at 1, 5, and 10 years was 73%, 32%, and 9%, respectively. The remaining 11 survivors exhibit few symptoms and are currently in New York Heart Association Class I or II.

CONCLUSIONS

Cardiac transplantation is a valid therapeutic option for patients with symptomatic hypertrophic cardiomyopathy who do not respond to optimal medical management and who are not candidates for conventional surgical treatment. The long-term outcome is excellent in these patients.

Sudden death in children and adolescents

OBJECTIVE

To identify the incidence, causes, and characteristics of sudden death at age 1-20 years.

DESIGN

A review of all deaths at age 1-20 years. Death certificates were obtained from the Office for National Statistics, and further information, where appropriate, from coroners, paediatricians, physicians, and pathologists.

SETTING

The resident population of one English health region in 1985-1994.

RESULTS

In a population of 806 500 children and adolescents aged 1-20 years there were 2523 deaths in 10 years. Medical causes accounted for 1017 deaths (40%); 1236 (49%) were unnatural, and 270 (11%) were sudden. These sudden deaths comprised 142 with a previous diagnosis, the commonest being epilepsy 49 (34%), cardiovascular disease 33 (23%), and asthma 30 (21%); 87 attributed to a cause discovered at necropsy, which was respiratory infection in 32 (37%), other infections in 17 (20%), and unsuspected cardiovascular abnormalities in 26 (30%); 41 remained unexplained.

CONCLUSIONS

Half of all sudden deaths in children or adolescents were attributed to an already diagnosed condition. Abnormalities identified at necropsy accounted for one third of sudden deaths. Undiagnosed hypertrophic cardiomyopathy caused less than one death per million person years in the population aged 1-20 years. Unexplained sudden death, which may be caused by primary cardiac arrhythmia, is probably about 10 times more common.

Ancillary autopsy--forensic histopathology and toxicology

Under the Coroners Act 1988 and the Coroners Rules 1984, the removal of parts or contents of the body which does not bear directly upon the cause of death is restricted. However, it may not be possible in every forensic necropsy to foretell whether the post-mortem removal of body tissue will fulfil a statutory proviso. To emphasize this medico-legal predicament, some examples in which ancillary histopathological examination or toxicological analysis assisted in ascertaining an accurate cause and manner of death are presented as short cases.