One-Year Follow-Up Results of MIS-C Patients with Coronary Artery Involvement: A Multi-center Study

Multisystem inflammatory syndrome (MIS-C) in children is a rare complication of SARS-CoV-2 infection. Knowing the course of the affected or unaffected coronary arteries in the patients under follow-up is important in terms of defining the long-term prognosis of the disease and determining the follow-up plan. This is a multicenter and retrospective study. The data were obtained from nine different centers. Between May 2020 and August 2022, 68 of 790 patients had coronary artery involvement. One-year echocardiographic data of 67 of 789 MIS-C patients with coronary artery involvement were analyzed. Existing pathologies of the coronary arteries were grouped as increased echogenicity, dilatation and aneurysm according to Z scores, and their changes over a 1-year period were determined. The data of all three groups are defined as frequency. SPSS Statistics version 22 was used to evaluate the data. In our study, aneurysm was observed in 16.4%, dilatation in 68.7% and increased echogenicity in 13.4% of the patients. All of the patients with involvement in the form of increased echogenicity recovered without sequelae by the end of the first month. No progression to aneurysm was observed in any of the patients with dilatation. No new-onset involvement was observed in patients with previously healthy coronary arteries during the convalescent period. In addition, from the sixth month follow-up period, there was no worsening in the amount of dilatation in any of the patients. At least 94% of the patients who completed the 12th month control period returned to normal.

Piccolo in transcatheter PDA closure multi-centre study from premature to adolescent children

In this multi-centre study, the mid- to long-term efficacy and safety of the Amplatzer Piccolo Occluder in patent ductus arteriosus closure in premature and term infants as well as children were discussed. Methods. Between 2016 and 2021, 645 patients, 152 of whom were less than 1 month old, underwent ductus closure with the Piccolo device from five different centres in Turkey. The median age of the patients was 2.2 years, and the mean narrowest point of duct diameter was 1.8 mm. Sixty-two patients weighed ≤ 1.5 kg, 90 patients 1.5-3 kg, and the mean follow-up was 20.4 months. In 396, the duct was closed by the retrograde route. Ductal anatomy was Type A in 285, C in 72, E in 171, and F in 64 patients. Fluoroscopy duration was 6.2 min. The procedure success rate was 99.1%. Device embolisation occurred in 13 patients (2%), and 11 were retrieved with a snare. Cardiac perforation and death developed in one premature baby. The left pulmonary artery and the descending aorta stenosis were observed in 3 (0.4%) and in 5 patients (0.5%). Results. Piccolo device is safe and effective in closing ductus in all age groups. It has low profile for use in premature and newborn babies, a small embolisation risk, and a low residual shunt rate after closure. Conclusion. The Piccolo device can be considered as close an ideal occluder. The lower profile, smaller delivery catheter size, and symmetry of this device allow for a venous or arterial approach.

Evaluation of the effect of obesity, dietary glycemic index and metabolic profiles on the cardiovascular risk in children with classical phenylketonuria

OBJECTIVES

To compare the glycemic index(GI),obesity,echocardiographic,and arterial stiffness measurements with the healthy control group to evaluate the cardiovascular risk of pediatric classical phenylketonuria(PKU).

METHODS

The study was a prospective observational,involving 104 pediatric volunteers between 2019 and 2020.Two groups were formed:the PKU patient group and the healthy control group.These two groups were further divided into three subgroups:obese,overweight,and normal weight.The patients' anthropometric measurements,body fat analysis,biochemical analysis, GI and glycemic load(GL),arterial stiffness measurements,and echocardiographic findings were recorded.

RESULTS

The PKU patient group's glucose,total cholesterol,LDL,and HDL values were significantly lower than the healthy control group(p = 0.010 for glucose and p = 0.001 for total cholesterol,LDL and HDL).Triglyceride levels were higher in the PKU patient group than in the healthy controls(109.6 vs. 76.7 mg/dl,p = 0.001). GI and GL were significantly lower in the PKU patient group than in the healthy control group(GI 453 vs. 392.9,p = 0.017 and GL 101.1 vs. 85.5,p = 0.036).Left ventricular mass(LVM)-z-score and LVM index were significantly higher in the PKU group than in the healthy control group(LVM z-score 0.9 vs. 0.5,p = 0.014 and LVM index 38.9 vs. 32.7 g/m2.7,p = 0.001). A moderately statistically significant positive correlation was found between the mean phenylalanine(phe) value and pulse wave velocity(PWV) among the PKU patient groups(R: 0.477,p < 0.001).A moderately statistically significant positive correlation was also found between waist circumference and PWV in the PKU patient group(R:0.541, p < 0.001).

CONCLUSIONS

Our study found that close follow-up of phe levels and PWV is more critical than obesity, GI, and GL in the cardiovascular evaluation of classical PKU patients.A large number of multicenter pediatric studies are needed in this area.

Evaluation of Baseline Characteristics and Prognostic Factors in Multisystemic Inflammatory Syndrome in Children: Is It Possible to Foresee the Prognosis in the First Step?

Background: Two years after the first cases, critical gaps remain in identifying prognostic factors in multisystem inflammatory syndrome in children (MIS-C). Methods: This retrospective study included 99 patients with MIS-C hospitalized between August 2020 and March 2022 in a pediatric tertiary center. The patients were divided into two groups according to clinical severity (low- and high-risk). Prognostic values of baseline clinical and laboratory characteristics were evaluated with advanced statistical analysis, including machine learning. Results: Sixty-three patients were male, and the median age was 83 (3−205) months. Fifty-nine patients (59.6%) were low-risk cases. Patients aged six years and over tended to be at higher risk. Involvement of aortic or tricuspid valve or >1 valve was more frequent in the high-risk group. Mortality in previously healthy children was 3.2%. Intensive care unit admission and mortality rate in the high-risk group were 37.5% and 7.5%, respectively. At admission, high-risk patients were more likely to have reduced lymphocyte count and total protein level and increased brain natriuretic peptide (BNP), ferritin, D-dimer, and troponin concentrations. The multiple logistic regression model showed that BNP, total protein, and troponin were associated with higher risk. When the laboratory parameters were used together, BNP, total protein, ferritin, and D-dimer provided the highest contribution to the discrimination of the risk groups (100%, 89.6%, 85.6%, and 55.8%, respectively). Conclusions: Our study widely evaluates and points to some clinical and laboratory parameters that, at admission, may indicate a more severe course. Modeling studies with larger sample groups are strongly needed.

Percutaneous Closure of Atrial Septal Defects with the MemoPart Atrial Septal Occluder: The Early-Term Results of a Multicenter Study

Atrial septal defect (ASD) is a common congenital heart disease with left-to-right shunt that may lead to pulmonary hypertension over time. Secundum ASD closure with transcatheter technique is currently the preferred method. The aim of this study was to evaluate the clinical experience and early-term outcomes of patients treated with a MemoPart ASD occluder device between June 2013 and June 2019. Fifty-six patients (35 females) with a mean age of 9.4 ± 6.6 years (range: 2-44 years) were included in the study. The diameters of the devices used to close the ASDs were 7-28 mm. The ratio of the device/defect diameter was 1.14:1. Atrial septal defect closure was applied successfully in all patients. The MemoPart septal occluder is a safe and effective device for ASD closure. In wide ASDs and cases with more than one deficient rim, weak rims, or wide and complicated cases, it can be used carefully with sufficient experience.

Aspirin-induced hepatotoxicity and anemia in children with acute rheumatic fever

BACKGROUND

The aim of this study was to investigate the frequency of anemia and hepatotoxicity associated with aspirin use in patients with acute rheumatic fever.

METHODS

Patients with acute rheumatic fever followed at Erciyes University, Faculty of Medicine, Department of Pediatric Cardiology between 2015-2018 were reviewed retrospectively.

RESULTS

A total of 286 patients with acute rheumatic fever were analysed. Aspirin treatment was started in 53 of the 286 patients (18.5%) due to arthritis. The mean age of the patients who used aspirin was 10.7 ± 2.5 years. Aspirin-induced hepatotoxicity developed in 9 (17%) of the 53 patients. Naproxen or ibuprofen was given to these patients as an alternative to aspirin. No side effects occurred in patients receiving naproxen or ibuprofen. In addition, 30% of 53 patients were initially anemic. The mean duration of aspirin use in the hepatotoxic patients who had anemia was longer than patients without anemia (p=0.02).

CONCLUSIONS

Patients with acute rheumatic fever should be closely monitored for aspirin hepatotoxicity. When aspirin hepatotoxicity develops, naproxen or ibuprofen treatment can be used safely.

The number and activity of CD3+TCR Vα7.2+CD161+ cells are increased in children with acute rheumatic fever

BACKGROUND

Acute rheumatic fever (ARF) is an autoimmune disease caused by group A β-hemolytic streptococci (GAS) and may develop into rheumatic heart disease (RHD). The pathogenesis of ARF and RHD involves molecular mimicry and antibody-mediated mechanisms. T cell involvement is described in various stages of the disease. Mucosal associated invariant T (MAIT) cells are enriched at the mucosa and are present in the blood and may be activated by GAS.

METHODS

In this study, we investigated the quantity and activity of CD3⁺TCRVα7.2⁺CD161⁺ cells in the active and recovered ARF patients and healthy controls. Twenty newly diagnosed, 20 recovered-ARF children, and 20 healthy controls were enrolled in the study. Peripheral blood (PB) mononuclear cells were isolated by Ficoll-Paque density gradient. CD4⁺, CD4^- subsets of CD3⁺CD161⁺TCRVα7.2⁺ cells and IFN-γ and TNF-α production were quantified by Flow cytometry.

RESULTS

Acute and recovered ARF patients had significantly elevated the number of CD3⁺TCRVα7.2⁺CD161⁺ cells in their PB. Both CD4⁺ and CD4^- subsets were increased. Moreover, total CD3⁺TCRVα7.2⁺CD161⁺ cell numbers were significantly higher in the recovered patients' PB compared with active ARF patients. In addition, CD3⁺TCRVα7.2⁺CD161⁺ cells in both acute and recovered patients produced significantly more IFN-γ and TNF-α. Non-MAIT total CD3⁺ T cell, CD4⁺ and CD4^- T cell subsets were also increased in active and recovered ARF patients and they also produced more IFN-γ and TNF-α.

CONCLUSION

Our data reveal that CD3⁺TCRVα7.2⁺CD161⁺ cells are elevated and actively producing IFN-γ and TNF-α in acute and recovered ARF patients and may contribute to ARF pathology.

Role of kallistatin in pediatric patients with pulmonary arterial hypertension

BACKGROUND AND OBJECTIVES

Kallistatin, a serine proteinase inhibitor, exerts its effect by vascular repair, angiogenesis inhibition, strong vasodilation, inhibition of vascular endothelial growth factor (VEGF), antiinflammation, and anti-apoptosis. We hypothesized as to whether it has a protective role in pulmonary arterial hypertension (PAH).

METHODS

The study included 5 subgroups (78 patients; 44 male): Eisenmenger syndrome (n=16), PAH with left to right shunt (n=20), idiopathic PAH (n=7), patients with left to right shunt without PAH (n=19), and patients with innocent heart murmur (n=16). Physical examination, chest radiography, electrocardiography, and transthoracic echocardiography (TTE) were performed for each patient. PAH diagnosis was confirmed by catheterization. Serum kallistatin, tumor necrosis factor alpha (TNF-α), Interleukin-10 (IL-10) and N-terminal pro b-type natriuretic peptide (NT-proBNP) levels were studied for each patient.

RESULTS

The lowest median kallistatin value was found in Eisenmenger syndrome: 1.19 (0.87-3.30) μg/ml. The highest value belonged to control group with innocent murmur: 2.89 (1.19-5.66) μg/ml. Serum levels of kallistatin were significantly lower in patients with PAH (p < 0.05). TNF-α values were increased and IL-10 values were decreased in pulmonary hypertension. However; no correlation was found between kallistatin levels and cytokines.

CONCLUSIONS

Kallistatin may have a protective effect in pulmonary arterial hypertension by repairing vascular damage, inhibition of angiogenesis, strong vasodilator effect, inhibiting VEGF, and anti-inflammatory mechanism of action. To our knowledge, our study is the first one that shows the role of kallistatin in pulmonary hypertension. Kallistatin may represent a promising novel therapeutic approach for pulmonary hypertension in the near future.

Percutaneous ASD closure of children weighing less than 10 kg

Background: Traditionally the procedure of percutaneous ASD closure is carried out in children weighing more than 15 kg. The aim of this study was to discuss the success, efficacy and safety of the percutaneous closure of symptomatic ASD in children weighing less than 10 kg. Material and methods: This study was performed in two centres. A total of 44 patients were included. Demographic and angiographic data of these patients were gathered retrospectively from patients' records. Main indications for ASD closure were: failure to thrive, recurrent respiratory infections, bronchopulmonary dysplasia and genetic syndromes. Results: Median weight of patients was 9.0(8.12-9.50) kg. Bodyweight of 22 patients was less than 3 percentiles. In the follow-up, this number was lowered to 9 patients at 12 months. Median age of patients was 18.0(12.0-285) months. Minimum age and weight of patients was 3 months and 4.5 kg, respectively. Median mean pulmonary pressure was 24.0(20.0-29.5). The values of median defect size were measured in Cath lab as 13.0(10.75-15.3) mm. Median device size was 13(9-15) mm. Defect size was evaluated according to body weight and body surface area. The ratio of weight per defect size was 0.65(0.54-0.84) also the ratio of body surface area per defect size was 0.032(0.028-0.04). The ratio of total septum per device diameter was 2.5(2.1-3.1). Types of devices used were Amplatzer Septal Occluder, Cera Flex Septal Occluder, Figulla Flex II Atrial Septal Occluder, Memopart Septal Occluder. All cases were closed successfully, but the device had to be retrieved in one patient after successful positioning because it was detected that device compressed the aorta. No major complications were seen. Conclusion: In the experienced centres, percutaneous ASD closure can be done effectively and safely in symptomatic children weighing less than 10 kg.

Can microsomal RNA be a biomarker in pulmonary hypertension secondary to bronchopulmonary dysplasia?

AIMS

In long-term follow-up, pulmonary hypertension (PHT) may develop in these patients with bronchopulmonary dysplasia (BPD). Microsomal RNAs (miRNAs) are a class of noncoding single-strand RNAs. It was shown that miRNA dysregulation contributes to PHT. Up until now, miRNA levels have not been studied in BPD to detect PHT. The main aim of this study is: miRNAs play role in PHT etiopathogenesis in BPD. They can be used as a feasible biomarker for early detection and follow-up of PHT in children with BPD.

METHODS

The study included infants who were admitted to the Neonatology Clinic. In all subjects, transthoracic echocardiography was performed by the same pediatric cardiologist. Expression of 25 miRNAs was studied from peripheral blood samples at the time of diagnosis.

RESULTS

Patients were categorized according to whether they have PHT and BPD. Group 1 included 21 infants who had both BPD and PHT. Group 2 had 17 infants who were diagnosed as BPD but had no PHT. Group 3 was a control group and had 21 infants who did not have BPD and PHT. Significant differences in the expression of 19 of 25 miRNAs were detected. Fifteen of these were in group 1.

CONCLUSIONS

Pulmonary hypertension is a disorder developing due to environmental and genetic reasons, in which the underlying mechanism is not fully understood. The genes controlled by miRNAs found to be related to PH in our study may have a role in PHT. In the future, it could be possible to establish novel approaches that may contribute to early diagnosis and treatment of PHT by focusing target genes of miRNA found to be related in this study.

Syncope due to complete atrioventricular block and treatment with a transient pacemaker in acute rheumatic fever

Various rhythm and connection disorders can be seen in the acute phase of acute rheumatic fever. First degree atrioventricular block, one of the minor signs of acute rheumatic fever, is the most common connection disturbance in this disease. Complete atrioventricular block, which seriously affects the conduction pathways, is rare in the literature. A 15-year-old boy was admitted because of syncope caused by complete atrioventricular block and a temporary pacemaker was employed because of symptomatic complete atrioventricular block. The transient pacemaker treatment was terminated due to recovery of complete atrioventricular block on the third day of antiinflammatory treatment. Acute rheumatic fever should be kept in mind as a possible cause of acquired complete atrioventricular block. Connection disturbances in acute rheumatic fever improve with antiinflammatory treatment. Transient pacemaker treatment is indicated for patients with symptomatic transient complete atrioventricular block.

Percutaneous Ventricular Septal Defect Closure in Patients Under 1 Year of Age

Untreated ventricular septal defect (VSD) is an important cause of congestive heart failure in early infancy. Growth is impaired in this population, and surgical closure is challenging because of congestion in the lungs, making infants prone to respiratory infection, and because of their poor nutritional status. The aim of this study is to share our experience with percutaneous VSD closure in patients under 1 year of age. Patients with hemodynamically significant left-to-right shunt, less than 1 year of age, and with VSD diameter ≤ 6 mm were retrospectively included in the study between December 2014 and January 2017. The median length of follow-up was 8.5 (4-14.2) months. Twelve patients from 2 to 12 months of age, with a median weight of 6.75 (5.4-8) kg, were included. The mean VSD diameter as measured by angiography from the left ventricle side was 4.7 ± 0.25 mm, and from the right ventricle side was 3.4 ± 1.1 mm. All were of a perimembranous type except three, which were muscular. All defects were closed with the Amplatzer Duct Occluder II (ADO II) or the ADO II-additional size. The mean fluoroscopy duration and total radiation dose were 22.6 ± 18.7 min and 1674 ± 851 cGy/min, respectively. No aortic regurgitation associated with device closure was seen in any of the patients. Complete atrioventricular block occurred in one patient 6 months after the procedure, and was treated with a permanent pacemaker. VSD closure is challenging, regardless of whether a surgical or percutaneous procedure is used. The risks are higher for children younger than 1 year with low body weight. Percutaneous closure, which carries similar risks but is less invasive than surgery, may be the preferred alternative in early infancy.

Is hypertension the fate of aortic coarctation patients treated with Cheatham Platinum (CP) stent?

AIM

The aim of this study is to address the presence of hypertension and risk for cardiovascular diseases in patients with Coarctation of the Aorta (CoA) who were treated with endovascular stent placement.

METHODS

Twenty patients (mean age: 14.2 ± 3.9 years) who were treated with stent and 20 age- and sex-matched controls were included to the study. Structure and functions of left ventricle were assessed by echocardiography. Carotid intima media (CIM) thickness was measured by using sonography as a marker for detecting cardiovascular risk. As indirect marker of arterial stiffness, pulse wave velocity, and augmentation index were recorded by ambulatory blood pressure monitorization/arteriography device.

RESULTS

By ambulatory blood pressure monitorization, 24 h and daytime systolic and mean arterial pressure values were found to be significantly higher in patient group. Based on percentile values, 15% and 5% of patients were pre-hypertensive and hypertensive, respectively. Pulse wave velocity and cardiac output values were found to be significantly higher than control group. CIM thickness was also found to be significantly higher in patient group when compared to controls.

CONCLUSIONS

It was shown that hypertension incidence as demonstrated by ambulatory blood pressure monitorization and risk for cardiovascular diseases as indicated by CIM thickness and Pulse wave velocity were higher than those in healthy population even after CoA is corrected.

Patent Ductus Arteriosus closure in preterms less than 2kg: Surgery versus transcatheter

BACKGROUND

As new devices come into the market, percutaneous techniques improve and interventionalists become more experienced; percutaneous closure gets more common in preterms. In this study we aimed to compare efficacy and safety of Patent Ductus Arteriosus closure surgically versus transcatheter method in preterms <2kg. Best of our knowledge this study is the first one that compares outcomes of surgery and percutaneous Patent Ductus Arteriosus closure in preterms.

METHODS & RESULTS

Between the dates July 1997 to October 2014 in our center Patent Ductus Arteriosus of 26 patients <2kg were closed percutaneously (Group A) and 31 less than 2kg operated (Group B). Weight of patients in percutaneous Patent Ductus Arteriosus closure group was significantly more than the surgery group. Mean gestational age of the patients in Group A was 30±1.8weeks, in group B was 28.6±3.5weeks. In group A; all cases were closed successfully except 4 cases: device embolization in 2, cardiac tamponade and iatrogenic aortic coarctation were seen. Pneumomediastinum and chylothorax were the major complications of the surgery group. There was no statistically significance between complication and success rates between two groups.

CONCLUSION

Percutaneous Patent Ductus Arteriosus closure is the candidate for taking the place of surgery in preterms. However, it is not applied routinely; can only be done in fully equipped large centers by experienced interventionalists.

Early onset marfan syndrome: Atypical clinical presentation of two cases

Early onset Marfan Syndrome (eoMFS) is a rare, severe form of Marfan Syndrome (MFS). The disease has a poor prognosis and most patients present with resistance to heart failure treatment during the newborn period. This report presents two cases of eoMFS with similar clinical features diagnosed in the newborn period and who died at an early age due to the complications related to the involvement of the cardiovascular system.

Pulmonary arterial wall thickness in Eisenmenger Syndrome: Prospective, cross-sectional, controlled clinical trial

BACKGROUND

The aim of current study is to investigate echocardiographic pulmonary artery wall thickness (PAWT) association with angiocardiography, echocardiography, and biochemical findings and to demonstrate its predictive role in morbidity of disease.

METHOD

Nineteen patients with Eisenmenger Syndrome (ES) (13 females; a mean age of 12.0 ± 4.1 [min-max 4-17] years) and 24 (16 females; a mean age of 12.1 ± 4.3 [min-max 3-18 years]) healthy subjects as a control group were included in this prospective, cross-sectional, controlled clinical study between December, 2012 and December, 2013. PAWT were measured at the end of systole at the distal site of pulmonary valves at the parasternal short-axis. PAWT was compared with morbidity criteria of the disease such as functional class, pulmonary vascular resistance.

RESULTS

PAWT was higher in the patient group (P = 0.005) together with pulmonary arterial diameter (Z-score, P < 0.001), vena cava inferior diameter (P = 0.002), and right ventricular wall thickness (RVWT), while TAPSE was significantly lower (P = 0.002). PAWT was strongly positively correlated to RVWT (r = 0.893, P < 0.001) and moderate negatively correlated to TAPSE (r = 0.597; P < 0.011).

CONCLUSION

PAWT can be used as an additional parameter with other echocardiographic parameters in the follow-up of Eisenmenger Syndrome in children.

Anti-inflammatory role of obestatin in autoimmune myocarditis

Obestatin is a popular endogeneous peptide, known to have an autoimmune regulatory effect on energy metabolism and the gastrointestinal system. Studies regarding the anti-inflammatory effects of obestatin are scarce. The aim of this study was to show the anti-inflammatory effect of obestatin in an experimental model of autoimmune myocarditis in rats. Experimental autoimmune myocarditis was induced in Lewis rats by immunization with subcutaneous administration of porcine cardiac myosin, twice at 7-day intervals. Intraperitoneal pretreatment with obestatin (50 μg/kg) was started before the induction of myocarditis and continued for 3 weeks. The severity of myocarditis was evidenced by clinical, echocardiographic and histological findings. In addition, by-products of neutrophil activation, lipid peroxidation, inflammatory and anti-inflammatory cytokines were measured in serum. Obestatin significantly ameliorated the clinical and histopathological severity of autoimmune myocarditis. Therapeutic effects of obestatin in myocarditis were associated with reduced lipid peroxidation, suppression of polymorphonuclear leukocyte infiltration and enhancement of glutathione synthesis, inhibition of serum inflammatory and activation of anti-inflammatory cytokines. Histopathologically, the left ventricle was significantly dilated, and its wall thickened, along with widespread lymphocytic and histocytic infiltration. The myocardium was severely infiltrated with relatively large mononuclear cells. These histopathological changes were observed in lesser degrees in obestatin-treated rats. This study demonstrated a novel anti-inflammatory effect of obestatin in an experimental model of autoimmune myocarditis. Consequently, obestatin administration may represent a promising therapeutic approach for myocarditis and dilated cardiomyopathy in the future.

Efficacy of palivizumab prophylaxis among infants with congenital heart disease: A case control study

BACKGROUND

Palivizumab prophylaxis for RSV has been consistently reported to reduce the risk of hospital admissions related to RSV infection in children with symptomatic cardiac disease. This study was designed to investigate the efficacy of palivizumab prophylaxis among infants with congenital heart disease (CHD) in Turkey.

METHODS

A total of 91 infants with CHD who received palivizumab prophylaxis and 96 infants with CHD without prophylaxis (0-12 months:52; 12-24 months:44) were included in this single-center retrospective case control study. Data on patient characteristics, household environment, and LRTIs were evaluated.

RESULTS

In patients without prophylaxis, the rate of overall lower respiratory tract infections (LRTIs) (P < 0.001), complicated LRTIs (P = 0.006), LRTI-related hospitalization (P < 0.001) and ICU admission (P = 0.008) were significantly higher than control patients. Weight <10th percentile (odds ratio (OR) 5.78, 95% confidence interval (CI):1.37; 24.4, P < 0.001) and concomitant chromosome abnormality (OR 4.01, 95% CI:1.01;16.45, P < 0.001) in patients with prophylaxis, while presence of a sibling <11 years of age (OR 3.38, 95% CI: 1.21; 9.46, P < 0.001) and congestive heart failure (OR 8.63, 95% CI: 2.81; 26.6, P < 0.001) in the control group were the significant correlates of LRTI-related hospitalization.

CONCLUSION

Our findings revealed significantly lower rate of overall and complicated LRTIs, LRTI-related hospitalization and ICU admissions in infants with CHD via palivizumab prophylaxis.

Silent cerebral emboli following percutaneous closure of atrial septal defect in pediatric patients: a diffusion-weighted MRI study

PURPOSE

The aim of this prospective study was to investigate the incidence of silent cerebrovascular embolic events associated with percutaneous closure of atrial septal defect (ASD) in pediatric patients.

METHODS

A total of 23 consecutive pediatric patients (mean age, 10.4±3.8 years; range, 4-17 years) admitted for transcatheter closure of ASD were recruited in the study. The patients were scanned with a 1.5 Tesla clinical scanner. Two cranial magnetic resonance imaging (MRI) examinations were acquired before the procedure and within 24 hours following the catheterization. MRI included turbo spin-echo fluid-attenuated inversion recovery (FLAIR) sequence and diffusion-weighted imaging technique with single-shot echo-planar spin-echo sequence. The transcatheter closure of ASD was performed by three expert interventional cardiologists. Amplatzer septal occluder device was implemented for the closure of the defect. No contrast medium was administered in the course of the procedure.

RESULTS

None of the patients had diffusion restricted cerebral lesions resembling microembolic infarctions on postprocedural MRI. Preprocedural MRI of two patients revealed nonspecific hyperintense white matter lesions on FLAIR images with increased diffusion, which were considered to be older ischemic lesions associated with previously occurred paradoxical embolism.

CONCLUSION

The current study suggests that percutaneous closure of the ASD, when performed by experienced hands, may be free of cerebral microembolization in pediatric patients. However, due to the relatively small sample size, further studies with larger patient groups are needed for the validation of our preliminary results.

ADO II in Percutaneous VSD Closure in Pediatric Patients

OBJECTIVES

Main aim of our study to show that ADO II device can be used for the small ventricular septal defects successfully and safely with low complication rates in pediatric population.

BACKGROUND

It is hard to find an ideal device to use for every VSD successfully. If inappropriate device was chosen; complication rate increases, procedure time gets longer that prolongs exposure to ionizing radiation. Therefore interventionalists are in the search for new ideal devices.

MATERIAL

Between the dates April 2011-October 2014, 21 VSD closures with ADO-II device. were performed. Twenty patients were included, age ranged between 4 months 18 years. Weight of the patients was between 5-76 kg.

RESULTS

VSD diameter ranges between 2-6 mm (3.75 ± 1.25). VSD types were muscular in 2 patients, rest of them were perimembranous type. Most of the perimembranous defects (19/21) were aneursymatic and tunnel shaped. All the cases were successfully closed, no major complications were reported. There was no incidence of left bundle branch block, P-R prolongation, or complete heart block.

CONCLUSION

Considering perimembraneous ventricular septal defects as difficult and risky for percutaneous closure because of its proximity to aortic, atrioventricular valves and conduction tissue, we suggest that ADO II device can be safely and effectively used for such defects in particular if an aneurysm formation is present which is also compatible with the literature.

Cardioprotective effect of metformin against doxorubicin cardiotoxicity in rats

Objective:

The clinical use of doxorubicin, which is a strong antineoplastic agent, is limited due to its cardiotoxic side effects. Metformin is a drug with antihyperglycemic effects, and it has been shown to have a cardioprotective effect on left ventricular function in experimental animal models of myocardial ischemia. The present study investigated the cardioprotective effect of metformin in rats with doxorubicin cardiotoxicity.

Methods:

Wistar albino rats were used in the study. Forty male, 10-week-old Wistar albino rats were randomly divided four groups. The control group rats were intraperitoneally administered saline solution twice a week, four doses in total. The doxorubicin group rats received doxorubicin (4 mg/kg, twice a week, cumulative dose: 16 mg/kg) intraperitoneally. The metformin group rats received metformin (250 mg/kg/day, every day for 14 days) via gavage. The doxorubicin + metformin group rats received doxorubicin and metformin at the same dose. Left ventricular functions were evaluated by using M-mode echocardiography one day after the last dose of doxorubicin. Heart tissue samples were histopathologically examined. Cardiomyocyte apoptosis was detected using in situ terminal deoxynucleotide transferase assay (TUNEL). Serum brain natriuretic peptide and C-type natriuretic peptide levels were measured. Catalase, superoxide dismutase, glutathione peroxidase, and tumor necrosis factor alpha levels were analyzed in the heart tissue. The assumptions of equality of variances and normal distribution were checked for all variables (Shapiro-Wilk test and Q-Q graphics). To identify intergroup differences, one-way variant analysis or the Kruskal-Wallis test was used. A p<0.05 value was accepted as statistically significant.

Results:

Our results showed that doxorubicin treatment caused significant deterioration in left ventricular functions by echocardiography, histological heart tissue damage, and increase in cardiomyocyte apoptosis. Doxorubicin + metformin group showed protection in left ventricular function, elimination of histopathologic change, and reduced of cardiomyocyte apoptosis.

Conclusion:

The present study provided evidence that metformin has cardioprotective effects against doxorubicin cardiotoxicity.

New modified balloon-assisted technique to provide appropriate deployment in the closure of large secundum atrial septal defect using amplatzer septal occluder in children

BACKGROUND

Transcatheter closure of secundum atrial septal defect (ASD) is accepted as a safe alternative method to surgery. However, the deployment of the device across the septum using the conventional method presents difficulties in large ASDs.

METHODS

In the modified balloon-assisted technique (modified BAT), a Tyshak balloon (Numed, Inc) is placed in one of the left pulmonary veins and a long sheath is placed in the right upper pulmonary vein. Through this sheath, the Amplatzer septal occluder is deployed to its proper position with the help of the Tyshak balloon, which prevents the left atrial disc from prolapsing into the right atrium. This method was implemented in the treatment of patients with a large secundum ASD. In this study, defects that measured ≥15 mm by transesophageal echocardiography (TEE) were considered to be large secundum ASDs. Between June 2011 and September 2013, the modified BAT was used in the closure procedure of 30 patients (18 females/12 males) with large ASDs (group I). Between September 2003 and September 2013, 78 patients (47 females/31 males) with large ASDs were treated with conventional methods (group II). The results of both groups were compared.

RESULTS

In the comparison of the results between group I and group II, there were no significant differences between mean maximal ASD sizes by transthoracic echocardiography, mean maximal ASD size by TEE, Qp/Qs ratio, mean device diameter, failure rate, embolization incidences, residual shunt, and fluoroscopy time. However, there were significant differences in the mean ages, mean body weights, and mean PAPs between group I and group II. After adjusting for age and body weight, in terms of process failure, the conventional method was found 5.6 times more risky compared to modified BAT.

CONCLUSION

Large secundum ASDs in children, transcatheter closure with Amplatzer septal occluder using the modified BAT is a simple, quite useful method. In addition, this method seems to reduce the procedure failure rate.

The role of N-terminal proBNP in the clinic scoring of heart failure due to dilated cardiomyopathy in children

BACKGROUND

We aimed to show sensitivity and specificity of NT-ProBNP in demonstrating the degree of cardiac failure caused by dilated cardiomyopathy (DCMP).

METHODS

From January 2006 to July 2012, thirty patients (2 - 168 months) who had DCMP with acute heart failure and 37 healthy children aged (1 - 168 months) were enrolled in this study. Clinical evaluation was done using a modified Ross scoring system. Ross scoring was done before and after treatment. Patients with a score of > 2 points were included in the study. Ross scoring, echocardiographic parameters, serum NT-ProBNP levels and cardiothoracic index (CTI) were measured before and on the 7th day of treatment. Patients were divided into 3 groups according to degree of heart failure.

RESULTS

While the change in logNT-ProBNP in the patient group following one-week of treatment was significant (p < 0.05), there was no marked significance in the changes in EF, FS, LVEDD, LVMIz, and CTI. There was a statistically significant difference between logNT-ProBNP levels each Ross clinical group not only before treatment but also on assessment on the 7th day of treatment in the patient group (p < 0.001, Tukey's and Tamhane's T2 post-hoc tests). No significant difference was detected between EF, FS, LVEDDs, LVMIz, and CTI and the stages of acute cardiac failure. The NT-ProBNP levels of patients who became clinically asymptomatic after treatment but still had left ventricular systolic dysfunction were statistically significant when compared to the control group. The cut off value to distinguish healthy children from the patients with left ventricular systolic dysfunction caused by cardiomyopathy was found as 174.3 pg/mL.

CONCLUSIONS

NT-ProBNP levels are more effective than conventional echocardiographic parameters for clinical determination of the stage of cardiac failures in children with left ventricular systolic dysfunction due to DCMP. Therefore, it can be used for determining the treatment and management of such patients. Furthermore, the test is simple and beneficial, because of its availability in most clinical chemistry laboratories and its advantage of allowing frequent measurements and assessments.

Transcatheter closure of ruptured sinus Valsalva aneurysm with retrograde approach

A three-year-old girl with multiple heart malformations admitted to the pediatric cardiology unit because of excessive sweating and fatigue. Abnormal color Doppler flow was detected into the right atrium from the dilated coronary sinus on the echocardiographic examination, and ruptured sinus Valsalva aneurysm (SVA) was diagnosed. Although in most such cases, an antegrade transcatheter approach has been used, a retrograde approach can be used as a cost-effective treatment modality in those cases with selective high-risk surgery. In this report, we present a patient with ruptured SVA, which was closed via Amplatzer vascular plug-4 by retrograde approach.

Are endothelial microparticles early markers of pulmonary hypertension?

OBJECTIVE

To find out the relation between endothelial microparticles (EMPs), pulmonary arterial stiffness and thickness of pulmonary artery intima media to determine the prognosis of Eisenmenger syndrome and their correlation with echocardiographic and hemodynamic parameters.

METHODS

Sixteen patients with Eisenmenger syndrome and 37 control patients were included. Electron microparticles levels, angiographic and echocardiographic findings were compared.

RESULTS

Thickness of pulmonary arterial intima media and systolic and diastolic diameters of pulmonary artery were found significant in the patient group. CD144 and CD146 EMP values of patient group were statistically high. However, there was not any significant difference in pulmonary arterial strain, elasticity and stiffness. Positive significant relationship was found between pulmonary artery intima media thickness and CD144 in patient group. But there was not any significance between CD 146 and pulmonary artery intimamedia thickness.

CONCLUSIONS

Invasive methods remain as the gold standard for pulmonary hypertension diagnosis, follow-up and treatment, but it is risky and can even be fatal. Our study showed that EMPs, thickness of pulmonary artery intima media and pulmonary stiffness could be novel noninvasive modalities for the follow-up pulmonary hypertensive patients.

Do we need a femoral artery route for transvenous PDA closure in children with ADO-I?

OBJECTIVE

The standard procedure in percutaneous closure of patent ductus arteriosus (PDA) with Amplatzer duct occluder-I (ADO-I) is transvenous closure guided by aortic access through femoral artery. The current study aims to compare the procedures for PDA closure with ADO-I: only transvenous access with the standard procedure.

METHODS

This study was designed retrospectively and 101 pediatric patients were included. PDA closure was done by only femoral venous access in 19 of them (group 1), arterial and venous access used in 92 patients (group 2) between 2004 to 2012 years. The position of the device and residual shunt in group1 was evaluated by the guidance of the aortogram obtained during the return phase of the pulmonary artery injection and guidance of transthoracic echocardiography. Shapiro-Wilk's test, Mann-Whitney U, chi-squared tests were used for statistical comparison.

RESULTS

The procedure was successful in 18 (95%) patients in group 1 and 90 (98%) patients in group 2. Complications including the pulmonary artery embolization (n=1), protrusion to pulmonary artery (n=1), inguinal hematoma (n=3), bleeding (n=2) were only detected in group 2. In other words, while complications were observed in 7 (7.2%) patients in group 2, no minor/major complication was observed in group 1. Complete closure in group 1 was: in catheterization room 14 (77.8%), at 24th hour in 2 (11.1%), at first month in 2 (11.1%). Complete closure in group 2 was: 66 (73.4%) patients in the catheterization room, 21 (23.3%) at 24th hour, 3 (3.3%) at first month, complete closure occurred at the end of first month.

CONCLUSION

In percutaneouse PDA closure via ADO-I, this technique can be a choice for patients whose femoral artery could not be accessed, or access is impossible/contraindicated. But for the reliability and validity of this method, randomized multicenter clinical studies are necessary.

Different clinical presentations of Naxos disease and Carvajal syndrome: Case series from a single tertiary center and review of the literature

Objective

Naxos disease is an autosomal recessive, inherited, cardiocutaneous disorder, characterized by arrhythmogenic right ventricular cardiomyopathy, woolly hair, and palmoplantar keratoderma. Carvajal syndrome is characterized by palmoplantar keratoderma, curly hair, dilated cardiomyopathy, especially on the left ventricle side, and early morbidity. The aim of this study was to evaluate the cutaneous and cardiac findings and genotype-phenotype relationship of six patients diagnosed with Naxos/Carvajal syndrome.

Methods

A retrospective review of six cases diagnosed with Naxos/Carvajal syndrome at our institution from 2002 to 2012 was performed. Demographic data; presenting complaints; cutaneous and cardiac findings; electrocardiography, echocardiography, and genetic analysis results; and treatment data were obtained from patient files.

Results

The patient group was composed of 4 males and 2 females, ranging from 1.5 to 13 years, with a mean age 6.4 years. Typical cutaneous and hair findings were present in all patients. Two cases presented with ventricular tachycardia attack, and 2 cases presented with severe heart failure. Two cases had only cutaneous findings without cardiac involvement at diagnosis. An implantable cardioverter-defibrillator was implanted in one case due to ongoing recurrent ventricular tachycardia attacks despite various antiarrhythmic treatments. Three of the 6 patients died during the follow-up.

Conclusion

For cases with woolly hair and palmoplantar keratoderma, the physician should provide a cardiac assessment, considering Naxos/ Carvajal disease associated with cardiomyopathy. When an early diagnosis is made, the life expectancy may be increased by treatment of heart failure and arrhythmias; also, genetic counseling should be performed.

Unusual right ventricle aneurysm and dysplastic pulmonary valve with mitral valve hypoplasia

We report a newborn with an unusual combination of aneurysmally dilated thin-walled right ventricle with hypertrophy of the apical muscles of the right ventricle. There was narrow pulmonary annulus, pulmonary regurgitation, and hypoplasia of the mitral valve and left ventricle. We propose that this heart represents a partial form of Uhl's anomaly.

The effects of dexmedetomidine on early stage renal functions in pediatric patients undergoing cardiac angiography using non-ionic contrast media: a double-blind, randomized clinical trial

BACKGROUND

In this study we aimed to investigate the effects of dexmedetomidine on early stage renal function in pediatric patients undergoing cardiac angiography.

METHODS

60 pediatric patients between 6 and 72 months of age undergoing cardiac angiography were included in the study. Patients were divided into two groups. The patients in both groups were administered 1 mg · kg(-1) ketamine, 1 mg · kg(-1) propofol as bolus and followed by 1 mg · kg(-1) · h(-1) ketamine and 50 μg · kg(-1) · min(-1) propofol infusion. Additionally, a loading dose of 1 μg · kg(-1) dexmedetomidine given over 10 min followed by 0.5 μg · kg(-1) · h(-1) dexmedetomidine infusion to patients in group D. The patients were evaluated for NGAL, creatinine, renin, endothelin-1, TAS and TOS blood levels before the procedure and 6th and 24th h after the procedure. pRIFLE criteria were used to define CIN and its incidence in the study.

RESULTS

According to pRIFLE criteria contrast-induced acute kidney injury developed in 3 (10%) of the patients in group D and 11 (36.7%) of the patients in group C (P = 0.029, risk ratio = 0.27; 95% CI: 0.084-0.88). In patients who developed CIN, Endothelin-1 levels in groups C and D were significantly higher than baseline levels at 6th, 24th and 6th h, respectively. Renin levels were significantly increased at 6th and 24 th( ) h in patients with CIN in both groups.

CONCLUSIONS

Dexmedetomidine may be beneficial in protecting against contrast-induced nephropathy during pediatric angiography by preventing the elevation of vasoconstrictor agents such as plasma endothelin-1 and renin.