Left ventricular dysfunction in a child with asymptomatic pre-excitation: Cure with catheter ablation

Wolff-Parkinson-White syndrome, is known to cause left ventricular dysfunction or dilated cardiomyopathy secondary to sustained tachycardia in infants and children. However, left ventricular dysfunction secondary to pre-excitation related abnormal ventricular activation has been reported in a limited number of cases. This condition should be recognized early, as catheter ablation of the accessory pathway can permit rapid ventricular function improvement. In this paper, we present a 2.5-year-old patient diagnosed with tachycardia-free Wolff-Parkinson-White syndrome with a right free wall accessory pathway and depressed cardiac function, whose left ventricular function is completely restored after successful catheter cryoablation.

Interventional cardiac catheterization in neonates and premature infants with congenital heart disease: a single center experience

BACKGROUND

The increased survival of patients with congenital heart disease over the last three decades has been associated with improvements in diagnosis and treatment. This study aimed to evaluate therapeutic interventional catheterization, outcomes and complications of these procedures in neonates and premature infants.

METHODS

In this study, therapeutic catheterization procedures performed on neonates and premature infants with congenital heart disease at a university hospital between February 2000 and October 2019 were retrospectively evaluated.

RESULTS

A total of 322 procedures were performed on 279 neonates and 26 premature infants. Of the patients, 217 (67.4%) were male. The median age of the patients was 8 days (interquartile range [IQR] 2-20) and the median body weight was 3050 g (IQR 2900-3600). The most common procedures were balloon atrial septostomy, balloon aortic angioplasty, balloon pulmonary valvuloplasty and balloon aortic valvuloplasty (35.4%, 20.8%, 18.3% and 12.4% respectively). The most common diagnoses were transposition of the great arteries, coarctation of the aorta, pulmonary stenosis and aortic stenosis (26.7%, 19.3%, 15.2% and 11.5% respectively). Most procedures, 274 (85.1%), were successful. Complications were observed in 74 procedures (23%). Of these complications, 45 (14%) were minor and 29 (9%) were major. The most common complication was transient dysrhythmia (6.9%). There was no significant relationship between body weight, age and the rate of complications. However, longer procedure time and fluoroscopy time were associated with higher complication rates (p < 0.05). Four procedurerelated deaths were observed.

CONCLUSION

Procedure-related complications are higher in the neonatal period. Although the complication rate varies according to the type of procedure, longer fluoroscopy time and procedure duration are associated with an increased complication rate. Procedures performed with the right indications, appropriate equipment and by experienced teams will play a key role in reducing complication rates.

Evaluation of the relationship between cardiopulmonary exercise test findings and clinical status in children and adolescents with congenital heart disease

BACKGROUND

The cardiopulmonary exercise test is accepted as a helpful diagnostic tool in risk stratification, evaluation of prognosis, and guiding treatment modality in adults with congenital heart disease. In this study, we present our experience with the use of cardiopulmonary exercise test in children with congenital heart disease in different physiological and anatomical classifications.

METHODS

In this retrospective study, 25 children and adolescents who applied to the pediatric cardiology outpatient clinic between 2017 and 2020 with the diagnosis of different types of congenital heart disease were included. Demographic characteristics, electrocardiogram, echocardiogram, cardiopulmonary exercise test, spirometry, pro-BNP values, and in selected 20 patients; cardiac MRI data were examined. The modified Ross classification was used for heart failure grading.

RESULTS

The mean age of the patients was 14.8 ±2.39 years. Fifteen (60%) of the patients were male and 10 (40%) were female. In the modified Ross classification, patients in group I-II had significantly higher maximum exercise time, heart rate reserve %, peak VO2, and VO2/kg values compared to those in group III (p=0.026, p=0.007, p=0.043, p= 0.018, respectively). Cardiopulmonary exercise test and spirometry values obtained from the patients were evaluated in the light of clinical and other laboratory findings, and surgical/interventional treatment was decided for 4 patients with the use of these test results.

CONCLUSIONS

Cardiopulmonary exercise test is a useful noninvasive diagnostic tool in guiding the treatment decision and predicting the prognosis of pediatric patients with congenital heart disease, who have borderline symptoms.

Pacemaker lead-induced tricuspid stenosis treated with percutaneous valvotomy

BACKGROUND

Tricuspid stenosis is an uncommon complication of ventricular pacemaker electrode implantation, with few cases reported in the literature.

CASE

We present an 18-year-old male who developed severe tricuspid stenosis 15 years after endocardial VVI pacemaker implantation for complete AV block following a surgically repaired ventricular septal defect.

CONCLUSION

In this case we have shown that percutaneous balloon valvuloplasty was performed and successful in treating this complication.

Retrograde transcatheter closure of anterior mitral valve leaflet perforation

Transcatheter closure of mitral valve leaflet perforation is a very rarely performed and a difficult procedure for repairing the defect. Herein, we are the first to report on both the safety and feasibility of percutaneous retrograde transcatheter closure of anterior mitral valve leaflet perforation with an AMPLATZER™ Duct Occluder II (6 mm × 6 mm, ADO II; Abbott Vascular, IL, USA) device in a 19-year-old patient with a severe mitral valve regurgitation following cardiac surgery.

General Concepts in Adult Congenital Heart Disease

Congenital heart disease in adults (adult congenital heart disease) is a growing burden for healthcare systems. While infant mortality due to congenital heart disease in the last four decades decreased by almost 3-fold, adult congenital heart disease prevalence increased by more than 2-fold in United States. Adult congenital heart disease prevalence is expected to increase steadily until 2050 in projections. Adult congenital heart disease is a multifaceted problem with many dimensions. This manuscript aims to provide an overview of the common adult congenital heart diseases and summarize important points in management of these diseases with possible problems and complications that the patients and the physicians face.

Kawasaki disease shock syndrome: a rare and severe complication of Kawasaki disease

Kawasaki disease is an acute systemic vasculitis that occurs most commonly in young children. It affects medium-sized muscular arteries and the coronary arteries are the predominant site of involvement. Morbidity and mortality is generally due to coronary artery aneurysms that develop during the chronic phase. Although it is well known that Kawasaki disease can cause myocarditis, tachycardia and heart failure during acute stage, Kawasaki disease shock syndrome has been recently described. It is characterized by hypotension, signs and symptoms of poor perfusion and a shock-like state. Herein we describe two cases of Kawasaki disease shock syndrome that were treated in the pediatric intensive care unit and followed a course without morbidity or mortality.

Radiofrequency catheter ablation of left-sided accessory pathways via retrograde aortic approach in children

BACKGROUND

We aimed to analyze the results of retrograde aortic radiofrequency catheter ablation of left-sided accessory pathways in children.

METHODS

Between January 2010 and September 2014, 25 children who underwent left-sided accessory pathway ablation with a retrograde aortic approach were evaluated retrospectively.

RESULTS

The mean age of the patients was 11.09±3.71 years. Seventeen patients were male (68%). The mean procedure and fluoroscopy times were 71.54±21.05 min and 31.42±19.57 min, respectively. Radiofrequency energy was delivered with 41.38±15.32 W at 52.38±5.45 °C. Sixteen patients (64%) presented with manifest preexcitation and, 9 had concealed accessory pathways. The location of accessory pathway was left lateral in 16 patients, posteroseptal in 5, left anterolateral in 2, and left posterolateral and left posterior in the remaining 2. The acute success rate was 96%. The patients were followed for a mean of 16.68±18.01 months. There were 2 recurrences. No major complications were observed in the periprocedural period. One patient had groin hematoma, another one had transient severe headache and vomiting. Trivial mitral regurgitation was noted in a patient, which remained the same throughout follow-up. None of the patients developed new aortic regurgitation, pericardial effusion, or thrombi at the site of ablation.

CONCLUSIONS

The retrograde aortic approach can be safely employed with a high success rate for ablation of left-sided accessory pathways in children.

Is transesophageal electrophysiologic study valuable in children with successful radiofrequency ablation of supraventricular tachycardia on follow-up for recurrence?

Objective:

The aim of this study was to evaluate the efficacy of transesophageal electrophysiologic study (TEEPS) for the determination of supraventricular tachycardia (SVT) recurrences in symptomatic and asymptomatic children after successful radiofrequency ablation (RFA) for SVT.

Methods:

A total of 66 patients who underwent TEEPS after successful RFA were included. The demographic features, symptoms of the patients, and the characteristics of the recurrences induced by TEEPS were evaluated. The arrhythmia types induced during RFA were compared with those induced by TEEPS in terms of the compatibility of the diagnosis.

Results:

Forty-two (63.6%) girls and 24 (36.4%) boys with a mean age of 11.8±3.4 years were followed-up for 44.1±15.7 months. The average time between RFA and TEEPS was 5.2±5.9 months. The diagnoses during RFA were atrioventricular nodal reentrant tachycardia (AVNRT) in 47 of 66 patients, atrioventricular reentrant tachycardia (AVRT) in 18 of 66 patients, and ectopic atrial tachycardia in 1 of 66 patients. SVT was induced by TEEPS in 2 of 25 symptomatic and 5 of 41 asymptomatic patients. The SVT inducibility rate was 5.5% (1/18) and 12.7% (6/47) in patients with AVRT and AVNRT, respectively. In addition, 85.7% (6/7) of all recurrences occurred within 3.5 months. The recurrences as AVNRT in 2 of 25 symptomatic patients occurred in the first month after RFA. AVNRT in 4 of 41 and AVRT in 1 of 41 asymptomatic patients were induced within 3.5 months and 15 months, respectively.

Conclusion:

TEEPS seems to be a valuable screening and diagnostic method for the determination of recurrence in symptomatic and asymptomatic children who underwent successful RFA.

Comparison of Transesophageal and Intracardiac Electrophysiologic Studies for the Diagnosis of Childhood Supraventricular Tachycardias

In this study, we aimed to compare the results of transesophageal electrophysiologic studies (TEEPS) and intracardiac electrophysiologic studies (IEPS) in a cohort of pediatric patients with SVTs. The medical records of children aged between 0 and 18 years who underwent TEEPS between January 2007 and June 2012 were systematically reviewed, and those without pre-excitation and who underwent subsequent IEPS were identified. Post-procedural diagnoses were compared for compatibility. A total of 162 patients were included in the study with a mean age at diagnosis 11.6 ± 3.6 years. Tachycardia was induced in 152 patients by TEEPS and in 154 patients by IEPS. Overall, in 147 patients, tachycardia was induced by both TEEPS and IEPS. Diagnoses were compatible in 135 out of 147 patients (91.8 %). Nine out of the 12 patients with discrepant results were diagnosed with atrioventricular-reentrant tachycardia (AVRT) and three with atrioventricular nodal reentrant tachycardia (AVNRT) after TEEPS. Following IEPS, TEEPS diagnosis of AVRT was revised to typical AVNRT in 5 patients and atypical AVNRT in 4 patients. Two of the 3 patients who were diagnosed as having AVNRT following TEEPS were confirmed to have atrial tachycardia after IEPS, while the other patient was diagnosed with AVRT. Tachycardia terminated spontaneously in 3 patients, while overdrive pacing was attempted to terminate the tachycardia in 149 patients, with a success rate of 93.2 % (139/149). The diagnostic compatibility between TEEPS and IEPS is quite high. A diagnostic discrepancy mostly occurs in patients diagnosed with AVRT by TEEPS, and the possibility of atypical AVNRT should be considered in patients with a VA ≥70 ms to avoid such discrepancies.

Interventional cardiac catheterization in infants weighing less than 2500 g

The aim of our study was to share our clinical experience regarding cases of interventional cardiac catheterization in low-weight infants. We retrospectively reviewed all interventional catheterizations performed in infants weighing 2500 g or less between March 2001 and October 2012. Twenty patients were included in the study. The procedures included balloon atrial septostomy in 8 patients, balloon pulmonary valvuloplasty in 7 patients, balloon aortic valvuloplasty in 3 patients and balloon angioplasty for coarctation in 2 patients. The mean age at catheterization was 11.9 ± 9.6 days (range, 1 to 31 days) and the mean weight, 2038 ± 480 g (range, 1100 to 2500 g). The mean procedure time was 80.3 ± 32 minutes, and the mean fluoroscopy time was 17.5 ± 12 minutes. Only two patients had no benefit from the intervention. One patient died at day 4 after catheterization, due to sepsis. Complications occurred in 3 patients: one patient developed atrial flutter and respiratory arrest, one patient developed apnea episodes, and one patient developed anemia that required transfusion. In conclusion, although studies investigating complications related to invasive cardiac catheterization in infants weighing less than 2500 g have reported increased complication rates, such complications were less likely to result in permanent sequelae. We did not observe significant complications related to the procedure; therefore, we would like to suggest that invasive cardiac catheterization can appropriately be performed in low-weight infants.

Clinical and electrophysiological evaluation of pediatric Wolff-Parkinson-White patients

Objective:

Wolff-Parkinson-White (WPW) syndrome presents with paroxysmal supraventricular tachycardia and is characterized by electrocardiographic (ECG) findings of a short PR interval and a delta wave. The objective of this study was to evaluate the electrophysiological properties of children with WPW syndrome and to develop an algorithm for the management of these patients with limited access to electrophysiological study.

Methods:

A retrospective review of all pediatric patients who underwent electrophysiological evaluation for WPW syndrome was performed.

Results:

One hundred nine patients underwent electrophysiological evaluation at a single tertiary center between 1997 and 2011. The median age of the patients was 11 years (0.1-18). Of the 109 patients, 82 presented with tachycardia (median age 11 (0.1-18) years), and 14 presented with syncope (median age 12 (6-16) years); 13 were asymptomatic (median age 10 (2-13) years). Induced AF degenerated to ventricular fibrillation (VF) in 2 patients. Of the 2 patients with VF, 1 was asymptomatic and the other had syncope; the accessory pathway effective refractory period was ≤180 ms in both. An intracardiac electrophysiological study was performed in 92 patients, and ablation was not attempted for risk of atrioventricular block in 8 (8.6%). The success and recurrence rate of ablation were 90.5% and 23.8% respectively.

Conclusion:

The induction of VF in 2 of 109 patients in our study suggests that the prognosis of WPW in children is not as benign as once thought. All patients with a WPW pattern on the ECG should be assessed electrophysiologically and risk-stratified. Ablation of patients with risk factors can prevent sudden death in this population.

Severe tricuspid regurgitation secondary to dislodgement of the atrial loop into the right ventricle: an unusual complication of pacemaker implantation in a young adult

Transvenous pacemaker leads may impair tricuspid valve function. Severe tricuspid regurgitation due to leaflet adhesion to the pacemaker lead has not been reported in a young adult patient in the literature. Our patient underwent a transvenous pacemaker implantation for symptoms of bradycardia. An atrial loop was created in the right atrium for future growth. After 10 years of follow-up, the patient was seen with severe tricuspid regurgitation and enlarged right heart structures due to migration of the atrial loop of the pacemaker lead into the right ventricle and adhesion of the lead to the tricuspid valve. Cardiac surgery and epicardial pacing was the chosen procedure to solve this problem. The venous system and right heart valves should be carefully observed during the follow-up of children who underwent transvenous pacing.