Camptodactyly-arthropathy-coxa vara-pericarditis syndrome and an unusual association with mitral stenosis

BACKGROUND

Campotodactyly-artrhropathy-coxa vara-pericarditis (CACP) syndrome is a very rare autosomal recessive genetic disorder. It is characterized by flexion contracture of the fifth finger (camptodactyly); noninflammatory arthropathy; decreased angle between the shaft and the head of the femur (coxa vara) and pericarditis. Its association with mitral stenosis has not yet been reported. Hereby we report this unique association with CACP syndrome.

CASE

An eleven-year-old girl presented with non-productive cough, dyspnea, and orthopnea. She was diagnosed CACP syndrome at the age of seven and a biallelic frameshift mutation in the PRG4 gene was determined. The physical examination revealed pectus excavatum, camptodactyly, genu valgum, tachypnea and orthopnea. The functional capacity was NYHA III-IV. She had 2/6 soft pansystolic murmur at 4th left intercostal space and a rumbling diastolic murmur at apex. Echocardiography revealed an enlarged left atrium, severe stenotic mitral valve with a mean diastolic transmitral gradient of 22.5 mmHg, mild mitral regurgitation and mild apical pericardial effusion. The patient had mitral comissurotomy and partial pericardiectomy operation. Her post-operative transmitral gradient decreased to 6.9 mmHg and the pulmonary pressure was 30 mmHg. Her functional capacity increased to NYHA I-II.

CONCLUSIONS

The main defect is the proteoglycan 4 protein which acts like a lubricant in articular and visceral surfaces. Therefore, the leading clinical feature is arthropathy. Cardiac involvement other than clinically mild pericarditis is not usually expected. Three types of proteoglycans (decorin, biglycan, and versican) are present in the mitral valve. This could be the reason of mitral valve involvement in rare cases as like ours. It is important that these patients undergo echocardiographic examination regularly.

Complications of cardiac catheterization in children with congenital heart disease

Tokel K, Gümüş A, Ayabakan C, Varan B, Erdoğan İ. Complications of cardiac catheterization in children with congenital heart disease. Turk J Pediatr 2018; 60: 675-683. Catheterization procedures for congenital heart disease include a broad range of procedures with a large spectrum of potential adverse outcomes. We aimed to determine the incidence of various complications during pediatric cardiac catheterizations and to designate the relative risk factors for such complications. All pediatric patients undergoing cardiac catheterizations between January 2005-December 2010 were included. Data are collected prospectively by filling out computerized catheterization reports. Patient records were scanned for potential risk factors retrospectively. Groups were divided based on cardiac diagnosis; type of procedure. Adverse events were categorized into major or minor events. A total of 2662 cardiac catheterizations were performed during this period. The mean age of patients was 53.2±64.3 months. Diagnostic catheterizations were done for 1797 (67.5%) patients, and interventional procedures were done in 865 (32.5%) cases. Adverse events were observed in 688 patients (26%) during 941 procedures. Minor and major events were seen in 21.4% and 7.1% of the procedures respectively. Most frequent major complications were anesthesia related (6%), most frequent minor complications were vascular complications (45.2%). Complications were more frequent in younger patients (p=0.0001), during interventional procedures (p=0.0001). Thirteen patients died after a cardiac catheterization; they were younger and had longer procedures compared to those who survived (p=0.0001). Vascular complications were frequent among younger patients, with prolonged procedure time and vessel access (p < 0.0001). Cyanotic patients had more complications (p < 0.05; OR for major and minor complications: 3.5 and 2 respectively). Minor complications were 2.7 times more likely in ventricular outflow obstructions (p < 0.05). The complication rates of cardiac catheterization in children are low, but not negligible. Defining risk factors will help anticipate adverse events, which will guide in preparation for rescue procedures and improvement of patient safety systems in catheterization laboratories.

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.

Does the z-score value of the abdominal aorta predict recoarctation in an infant?

OBJECTIVE

We evaluated left ventricular dimensions and aortic arch z-scores in infants who underwent balloon angioplasty (BAP) or surgery for coarctation of aorta (CoA). We searched for risk factors predicting recoarctation.

PATIENTS

Between 2007-2011, 27 male and 17 female infants (mean age 2.93 ± 4.78 months, range 2 days-24 months) with CoA were evaluated. Left ventricular dimensions, systolic functions, mitral and aortic annuli, transverse aortic arch, isthmus, coarctation site, and diaphragmatic aorta measurements were done and z-scores were determined before intervention.

RESULTS

Six patients underwent primary operation, 38 patients had BAP (86.4%). Associated cardiac pathologies in operated patients were double outlet right ventricle (n = 2), atrioventricular septal defect (n = 1), Ebstein's anomaly (n = 1), arch hypoplasia (n = 2). Twelve patients (27.2%) had simple coarctation. Ventricular septal defect was the most frequent associated cardiac pathology (n = 20, 45.4%). The patients were followed for 10.22 ± 8.21 months. Among 33 primary successful BAP's, 14 had recoarctation (42%). Eleven patients were primarily operated (including 5 with unsuccessful BAP), two had recoarctation (18%). Abdominal and transverse aorta values and z-scores were significantly lower in the recoarctation group (7.15 ± 2.12 mm and 6.07 ± 1.86 mm respectively in the "no-recoarctation group"; vs. 5.53 ± 0.75 mm and 4.94 ± 1.53 mm in the "recoarctation group" P <.05). Abdominal aorta z-score of 0.42 was 88.9% sensitive and 53.8% specific to predict recoarctation (area under ROC curve: 0.618-0.902, P <.05).

CONCLUSION

Although BAP for native coarctation is still a controversial treatment option due to frequent restenosis rates, abdominal aorta z-score of 0.42 could correctly eliminate recoarctation in 89% of these cases. This cutoff value might help us choose patients for primary BAP and decrease the recoarctation rate after BAP.

Crisscross heart with tricuspid atresia diagnosed in utero

Crisscross heart is a rare congenital cardiac anomaly in which systemic and pulmonary venous streams cross without mixing at atrioventricular level. We report a case of crisscross heart with tricuspid atresia, double outlet right ventricle, and pulmonary stenosis, which was diagnosed prenatally.

Total correction in tetralogy of Fallot with anomalous major coronary artery: an alternative method to conduit use

INTRODUCTION

A coronary artery anomaly precludes the use of a trans-annular patch in right ventricular outflow tract (RVOT) reconstruction. Herein we present three patients with coronary artery anomalies who underwent total corrective operations without using a conduit.

METHODS

Between 2007 and 2010, 84 patients with tetralogy of Fallot (TOF) were operated on. Nine (9.4%) of them had a coronary artery anomaly. Three (3.1%) of the patients were operated on using the double-outflow technique and two had a Blalock-Taussig shunt before the total corrective operation. In two patients, the left anterior descending artery (LAD) and in one, the right coronary artery (RCA) crossed the RVOT.

RESULTS

Postoperatively, the right-to-left ventricular pressure ratios were 0.45, 0.59 and 0.60 after cardiopulmonary bypass. No gradient was detected in the RVOT in postoperative echocardiographical measurements (< 15 mmHg gradient). In all three patients, there were moderate pulmonary insufficiencies. All were discharged home on the sixth day postoperatively. Mean follow-up duration was 9.8 ± 8 months. In the follow up of all three patients, there were moderate pulmonary insufficienciencies but no right ventricular dysfunction.

CONCLUSION

The 'double-outflow' technique is appropriate for TOF patients with a major coronary artery anomaly since it can easily be performed without the need of a conduit.

Giant right atrial myxoma leading to cardiac arrest in an infant

We present the case of a three-month-old infant with a giant right atrial myxoma obstructing the tricuspid valve, who following haemodynamic deterioration and cardiac arrest, was operated upon as an emergency. On echocardiogram, there was a mass attached to the tricuspid annulus, in close proximity to the septal leaflet, with dimensions of 16.6 × 12.5 mm. The mass was prolapsing through the tricuspid valve into the right ventricle and obstructing the inflow. While preparing for surgery, cardiac arrest occurred, so the patient underwent an emergency operation under cardiopulmonary resuscitation. The mass was excised without damaging the tricuspid valve and the conduction system. Histologically, the mass consisted of a myxoid matrix with scatted globoid and star-shaped myxoma cells. The patient stayed 15 days in the intensive care unit and was discharged home on the 20th day postoperatively. Although accepted as a benign tumour, a myxoma can display an aggressive clinical course in infants. In centres where cardiac operations cannot be performed, these patients need to be transferred to cardiac centres as soon as possible. Whatever the clinical presentation, we advocate immediate surgical extirpation of the tumour in order to avoid any unpredictable consequences in its clinical course.

Ictal electrocardiographic changes in children presenting with seizures

BACKGROUND

The aim of this study was to determine electrocardiographic changes in children during seizures.

METHODS

We assessed heart rate changes, RR intervals and QT changes during 47 seizures in children. Consecutive QT and RR intervals were measured for 60 s before the seizures, during the seizures and 60 s after the seizures during video electroencephalography monitoring.

RESULTS

There were 47 seizures in 18 patients. Five patients had generalized seizures and 13 patients had focal seizures. Twelve patients were male. The mean age during monitoring was 10.1 years (range 4 months-19 years). Ictal tachycardia was seen in every seizure. No ictal bradycardia was noted. There was only one dropped beat in a patient. The mean ictal heart-rate-corrected QT (QTc) interval was significantly higher than the postictal measurements (P= 0.005). Mean ictal QTc variation tended to increase during seizures and then decreased below the pre-ictal measurements in the postictal period. However these changes were statistically insignificant (P > 0.05). RR variance was significantly decreased during seizures compared to the postictal period and the standard deviation of the RR intervals was significantly decreased in the ictal period compared to the pre-ictal period (P= 0.014 and P= 0.001, respectively).

CONCLUSION

Tachycardia is the main finding in seizures in children. Ictal bradycardia and cardiac arrhythmias are very rare despite being more frequent in adults with seizures.

[Follow-up of our patients with transposition of the great arteries and arterial switch operation; comparison of simple and complex transposition cases]

OBJECTIVE

1. Follow-up data of patients with simple transposition of great arteries (TGA) and TGA with ventricular septal defect (VSD), who had arterial switch operation (ASO) are compared. 2. Factors affecting mortality and morbidity after ASO are described.

METHODS

Seventy-six patients, who had an ASO between April 2007 and August 2010 were studied retrospectively. The patients with intact ventricular septum (IVS) (n=36) were in Group 1, and those with VSD (n=40) in Group 2. The pre and postoperative clinical and echocardiographic variables and intensive care unit (ICU) outcomes were compared among groups using Mann-Whitney U, Pearson correlation and logistic regression tests.

RESULTS

The mean age at operation was 44.1 days, weight was 3.6±0.98 kg. Patients were followed for 15.5±11.21 months. The aortic cross-clamp (AoCC) and cardiopulmonary bypass (CPB) times were higher in patients with VSD (p=0.001, p=0.004). Patients in Group 1 had longer inotropic agent infusion (p=0.001). Length of stay in ICU was similar in two groups (p>0.05). There was no correlation between the length of stay in ICU and age, weight, CPB time, AoCC time. Aortic regurgitation was more frequent in Group 2 (p=0.02). During follow-up, 12 patients died (15.7%), and 8 patients had a revision operation (10.5%) (diaphragmatic plication in 4, pulmonary artery reconstruction in 1, recoarctation operation in 3 patients). Mortality was similar in groups (p>0.05).

CONCLUSION

Arterial switch operation provides anatomical correction in TGA. Appropriate timing and good perioperative planning facilitates low morbidity and mortality in patients with VSD as in patients with simple TGA.

Treatment of subaortic stenosis in hearts with single-ventricle physiology

BACKGROUND

We evaluated the patients who had had a Damus-Kaye-Stansel (DKS) operation for single-ventricular physiology with the aorta originating from a hypoplastic ventricle and the pulmonary artery from the systemic ventricle.

METHODS

Seven patients who were operated on between May 2007 and November 2010 were evaluated retrospectively. The patients had been diagnosed with a transposed double-inlet left ventricle and triscuspid atresia, and had been waiting for a Fontan operation. Systemic outflow stenosis was defined echocardiographically as those with a gradient greater than 20 mmHg, and angiographically those with greater than 5 mmHg in the subaortic region.

RESULTS

The mean age and weight of the patients was 15 ± 9.7 months and 8 ± 3.3 kg, respectively. The mean gradient between the systemic ventricle and the aorta was 35 ± 25 mmHg. This gradient decreased to 14.3 ± 4 mmHg postoperatively. The early hospital mortality was 14% (one patient). The mean extubation time and mean time in the intensive care unit (ICU) were 13 ± 7.3 hours and 2.2 ± 0.5 days, respectively. The mean follow-up time was 11 ± 2 months. No mortality and semi-lunar valve insufficiency were observed after discharge.

CONCLUSIONS

One of the major problems that occur while waiting for a Fontan operation is systemic ventricular hypertrophy and deterioration in the compliance of the ventricle due to systemic ventricular outflow stenosis. When the disadvantages of outflow resection are encountered, a DKS proves to be a good alternative.

Extension of coronary artery with double flap technique in a complicated arterial switch operation

The increased distance between the coronary ostium and the reimplantation site poses technical challenges in older patients with transposition of the great arteries (TGA) and complex coronary artery anomalies. In this report, we describe a technique for coronary artery reimplantation using a pedicle flap on the pulmonary artery (PA) to create a tunnel resulting in an extension of the coronary button.

Intraatrial baffle repair of anomalous systemic venous return without hepatic venous drainage in heterotaxy syndrome

A 7-month-old boy with heterotaxy syndrome had partial atrioventricular septal defect and interrupted inferior vena cava with hemiazygos continuation to a left superior vena cava. The left side of the common atrium receiving all the venous drainage was in connection with the left ventricle and the aorta. The small atrium and the proximity of the pulmonary and hepatic vein orifices precluded complete baffling. This report describes an intraatrial baffle repair of anomalous systemic venous return without hepatic venous drainage. This resulted in good oxygenation postoperatively, with oxygen saturation ranging from 93% to 98%.

Arterial switch and modified Konno procedure with detachment of the aortic root for transposition of the great arteries and left ventricular outflow tract obstruction

The arterial switch operation for the transposition of the great arteries accompanied by a ventricular septal defect and posterior malalignment of the outlet septum is a surgical challenge. We describe a new surgical technique in 2 patients having this pathology. The surgical technique consists of the arterial switch operation and a modified Konno procedure through partial detachment of the semilunar valve of the right ventricle as in the Ross procedure.

A rare anatomic variation: a combination of anomalous origin of the right subclavian artery from the main pulmonary artery, ventricular septal defect, and aortic coarctation

BACKGROUND

We present a rare case of an anomalous origin of the right subclavian artery (SA) from the pulmonary artery (PA) associated with ventricular septal defect (VSD) and aortic coarctation.

CASE REPORT

Critical aortic coarctation and VSD were diagnosed in a neonate, and coarctation angioplasty was successfully performed. Severe cardiac failure developed after this procedure, however, and closure of the VSD was planned.

RESULTS

The anomalous SA was diagnosed during the operation when the cardiopulmonary bypass was initiated. As the pulmonary blood flow decreased, a difference in pulse pressures between the right radial artery and the ascending aorta was noticed to be due to the subclavian steal phenomenon. The difference decreased from 60 mm Hg to 25 mm Hg following ligation of the SA at its origin from the PA. The patient was discharged on the eighth postoperative day without any problems.

CONCLUSION

An abnormal origin of the right SA from the main PA associated with VSD and aortic coarctation is a unique combination that, if unnoticed preoperatively, may create difficulties during the operation.

Somatic growth after corrective surgery for congenital heart disease

We report the somatic growth characteristics of 60 infants who underwent corrective surgery for congenital heart disease. Patients were assigned to the following groups: Group 1, cyanosis with pulmonary hypertension (PH); Group 2, cyanosis without PH; Group 3, large left-to-right shunt and PH; and Group 4, left-to-right shunt or obstructive heart lesion and no PH. Weight, length, and head circumference measurements and z scores were obtained before the operation, at 45 days, and 3, 6, and 12 months after the operation. Details about dietary intake, socioeconomic status at presentation, length of stay in the intensive care unit, hospitalization period, and perioperative events were noted. The endpoint was reaching a z score > -1 for all anthropometric measurements. At presentation, 51 patients (85%) had malnutrition. The family income, dietary intake, and presence of preoperative chronic malnutrition were interrelated and influenced the weight of the patient at all times during the postoperative follow-up (p < 0.05 for all values). The severity of the heart defect had no significant influence on the postoperative anthropometric measurements (p > 0.05). The lowest preoperative z scores for weight and height were observed in Group 3. Seven patients could not achieve the endpoint at the end of 12 months (4 in Group 3 and 3 in Group 2). Catch-up growth is attained mostly in the first year after corrective surgery. Delays in reaching z scores > -1 are observed in the chronically malnourished children. If adequate calories are provided and early corrective surgery is performed, the normal growth potential may be fulfilled.

Duplicate mitral valve in an infant with Shone's anomaly

Duplication of mitral valve is a very rare anomaly. It is characterized by two independent mitral valve apparatuses (leaflets and annulus) and subvalvular apparatuses (chordae and papillary muscles) that function well by themselves. In this report, we present duplicate mitral valve with parachute chordal attachment and mitral stenosis in an infant. The patient was successfully treated with the reconstruction of the larger valve without any intervention to the smaller one.

Constitutional growth delay pattern of growth in velo-cardio-facial syndrome: longitudinal follow up and final height of two cases

We report two patients with velo-cardio-facial syndrome (VCFS) who were admitted to our pediatric endocrinology clinic because of short stature and followed longitudinally until attainment of final height. Both patients followed a growth pattern consistent with constitutional delay of puberty with normal and near normal final height. Case 2 also had partial growth hormone (GH) deficiency and severe short stature (height SDS -3.4 SDS), but showed spontaneous catch-up and ended up with a final height of -2 SDS. These cases suggest that short stature in children with VCFS is due to a pattern of growth similar to that observed in constitutional delay of growth and puberty.

High-sensitivity C-reactive protein in children at risk for coronary artery disease

AIM

To determine the value of high-sensitivity C-reactive protein (hs-CRP) in predicting risk factors for coronary heart disease (CHD) in children.

METHODS

We measured hs-CRP levels in 51 children (11.79 +/- 3.14 years) with risk factors for CHD (hypercholesterolemia, hypertension, obesity, low HDL cholesterol and familial history of CHD). The results were compared with 26 children (12.98 +/- 2.59 years) without any risk factors.

RESULTS

The children with risk factors had significantly higher serum levels of hs-CRP compared to the control group (3.33 +/- 4.58 vs. 0.92 +/- 1.90 mg/L, respectively, p < 0.01). CRP concentrations significantly increased in children with three or more risk factors. Hs-CRP levels correlated to body mass index (r = 0.411, p = 0.003), diastolic blood pressure (r = 0.323, p = 0.021), fibrinogen (r = 0.447 and p = 0.004) and HDL cholesterol levels (r =-0.461 and p = 0.001). Cutoff value for CRP was 1.04 mg/L with 58% sensitivity and 92% specificity.

CONCLUSION

Serum hs-CRP level is a useful marker in screening the children who are under the risk of CHD in adulthood. Early identification of the children with risk factors and intervention for obesity, harmful habits and life style in childhood might decrease the incidence of coronary heart disease in adulthood.

Endocardial pacemaker implantation in neonates and infants

Transvenous pacemaker lead implantation is the preferred method of pacing in adult patients. Lead performance and longevity are superior and the implantation approach can be performed under local anaesthetic with a very low morbidity. In children, and especially in neonates and infants, the epicardial route was traditionally chosen until the advent of smaller generators and lead implantation techniques that allowed growth of the child without lead displacement. Endocardial implantation is not universally accepted, however, as there is an incidence of venous occlusion of the smaller veins of neonates and infants with concerns for loss of venous access in the future. Growing experience with lower profile leads, however, reveals that endocardial pacing too can be performed with low morbidity and good long-term results in neonates and infants.

Athlete's heart in prepubertal male swimmers

To determine the cardiac response to intensive endurance training during prepuberty, we studied 22 male prebubertal swimmers who had been trained for at least 3 years, with a mean of 3.91 years and a standard deviation of 1.10 years, and 8 hours per week, the mean being 10.0 hours and the standard deviation 1.7 hours. The control group consisted of 21 boys of similar age, height and weight (p is more than 0.05 for all), who were not participating regularly in sporting activities. Left ventricular dimensions and systolic function were examined with M-Mode; velocities and durations of transmitral flow were measured with pulsed wave Doppler; and tissue Doppler velocities and durations were measured with pulsed wave tissue Doppler echocardiography. We determined the regional velocities of the lateral mitral annulus in four-chamber position, the left ventricular posterolateral wall, and the midseptum in long-axis position. Interventricular septal thickness, left ventricular posterior wall thickness, left ventricular mass and relative wall thickness were increased in swimmers (p is less than 0.05). All the tissue Doppler measurements were similar in both groups, except the septal isovolumic relaxation time. We observed that the left ventricular wall thickness had increased concentrically in prepubertal swimmers compared to controls, without a significant change in the left ventricular diastolic diameter. This finding is contrary to the previous studies on adult swimmers. Whether the structural changes observed in our study reflect the unique cardiac adaptation of the hearts of children to exercise will only be disclosed by longitudinal studies of prepubertal athletes.

Cardiac echinococcosis with intra-atrial localization

Echinococcosis is a frequently encountered parasitic disease in the Mediterranean region, including Turkey. Cardiac disease is seen in 0.5-2% of patients. Usually the cysts are located within the pericardium or intramyocardially; intracavitary localization of the cyst is rarely seen. We herein report a patient who initially presented with hemoptysis and was echocardiographically diagnosed to have an intra-atrial hydatid cyst. Although patients with cardiac hydatid cysts may present with cardiac symptoms, symptoms typically involve other organ systems, following dissemination of the organism. Therefore, echocardiographic screening of patients who are diagnosed with echinococcosis, even if they have no cardiac symptoms, may ensure early diagnosis and prevent development of lethal complications, such as cyst rupture or embolization.

Active-fixation, steroid-eluting ventricular leads: the medium-term results in children

OBJECTIVE

Low threshold characteristics and mechanical stability are important features of an ideal pacing lead, especially for children. We report our experience and medium-term results with a steroid-eluting, active-fixation ventricular lead in children.

METHODS

Telectronics Accufix II DEC model 033-212 ventricular leads were implanted in 21 patients. Eighteen patients (11 male / 7 female; 10.6+/-4.0 years), who were followed for a mean period of 6.47 +/-1.13 years, were included in the study.

RESULTS

Pacemaker mode was DDDR in three patients, and VVIR in the remaining 15 patients. Mean threshold value was 0.5 volts at implant, which increased to 0.7 volts in the first month (p>0.05). It remained stable (0.62-0.78 V) until 5.5 years (p>0.05), increased significantly at 5.5 years (0.99+/-0.63 V at 5.5 years, p<0.05) and remained significantly high after this time (p<0.05). Pacing lead impedance did not differ significantly throughout the study (p>0.05). Thirteen pulse generators reached end-of-life at > or =4 years. In all the patients whose generators were replaced (11 patients), the leads were kept in place.

CONCLUSION

Steroid-eluting active-fixation ventricular leads have long service lives and low chronic stimulation threshold values, allowing lower outputs. These features may have advantages in pacing therapy of children.

Transcatheter closure of interatrial communications with Amplatzer device: results, unfulfilled attempts and special considerations in children and adolescents

OBJECTIVE

We report our clinical experience with the Amplatzer device in transcatheter closure of 80 atrial septal defects (ASD) in children.

METHODS

Among 99 patients (mean age: 7.2+/-3.8 years) with ASD selected by transthoracic echocardiography, procedures were performed in 80 patients under general anesthesia with fluoroscopic and transesophageal echocardiographic (TEE) guidance. Optimal device size was selected after stretched balloon sizing of the ASD's. The patients were discharged at 24 hours after an evaluation with X-ray, electrocardiography and echocardiography.

RESULTS

The mean follow-up period (FUP) was 38+/-14 months. Mean ASD size was 11.5+/-3.7 mm at TEE (stretched size: 17.6+/-3.9 mm). The mean size of the device was 18.6+/-4.0 mm. Procedure and fluoroscopy time were 52.1+/-17.8 minutes and 11.0+/-4.9 minutes, respectively. Immediately after the procedure 35 patients (43.8%) had residual shunts. Trivial shunt remained in only 2 of them (2.5%) after FUP. None of the patients had major complications. Minor and transient rhythm abnormalities were observed in 5 patients and trivial mitral regurgitation was seen in 6 patients.

CONCLUSION

Amplatzer is an effective and safe device for transcatheter closure of ASD especially in pediatric patients.

Prenatal echocardiographic diagnosis of congenital heart disease: comparison of past and current results

The increased experience in interpretation of fetal echocardiographic images may change the accuracy of fetal echocardiography in diagnosing fetal heart defects. We thus decided to evaluate the specificity and the sensitivity of our fetal echocardiographic examinations in diagnosing congenital heart disease, focusing especially on the outcome of complex cardiac pathologies. Between October 1999 and July 2003, 642 fetuses were followed until birth and underwent a postnatal reassessment of the cardiovascular system in our institution. These cases constitute our cohort. The postnatal reassessment was mainly done by echocardiography; some cases also had angiography. In case of intrauterine or postnatal death, an autopsy was performed. The prenatal and postnatal diagnoses were compared, and specificity and sensitivity of fetal echocardiography for congenital heart pathologies were determined. Among 45 affected pregnancies, 31 cases had complex and 14 had significant cardiac defects. The sensitivity of fetal echocardiography for cardiac anomalies was 93.3%; the specificity was 100%. Compared to our previous study, the sensitivity was remarkably improved (in our previous study sensitivity was 78% and specificity 100%). Echocardiography is a very useful and reliable tool in the evaluation of the fetal cardiovascular system, and has high sensitivity and specificity for congenital heart diseases.

A case of double-outlet left ventricle with atrioventricular discordance

The clinical, echocardiographic and angiographic aspects of a four-month-old boy with double-outlet left ventricle, atrioventricular discordance, L-malposition of the great arteries, ventricular septal defect and pulmonary stenosis are described. Additionally, in this patient, the right arcus aorta and the ligament of ductus arteriosus caused anterior compression of the trachea. The anterior position of the morphological left ventricle is the most interesting feature.

Increased QT dispersion in breath-holding spells

AIM

Breath-holding spells are common in infancy and early childhood, and patients are frequently referred to paediatric cardiology clinics for exclusion of heart disease. Recent data reveal subsequent development of epilepsy and neurocardiogenic syncope. Autonomic dysregulation and increased vagal stimulation leading to cardiac arrest and cerebral ischaemia is considered as the cause. Iron deficiency anaemia may be associated with these spells. We studied QT dispersion for the assessment of ventricular repolarization in these patients.

METHODS

The study group consisted of 19 girls and 24 boys between 3 and 108 mo of age (mean +/- SD = 22.7 +/- 17.7 mo); and the control group consisted of 13 girls and 12 boys between 3 and 57 mo of age (mean +/- SD = 22.9 +/- 15.1 mo). QT interval was measured; corrected QT interval (QTc), QT dispersion (QTd) and QTc dispersion (QTcd) were calculated from 12-lead surface electrocardiograms of the patients and the control group.

RESULTS

There was no statistically significant difference in terms of QT and QTc intervals between patient and control groups, while QTd and QTcd values were significantly increased in patients with breath-holding spells compared to the healthy children. QT dispersion was 59.5 +/- 35.9 ms and 44.8 +/- 11.9 ms, respectively, in patients and controls (p < 0.05). QTc dispersion was 102.1 +/- 41.9 ms and 79.6 +/- 24.6 ms, respectively (p < 0.01). The presence of iron deficiency did not effect the QT and QTc dispersion.

CONCLUSION

QT dispersion is increased in patients with breath-holding spells, and this finding justifies further investigation for rhythm abnormalities and autonomic dysfunction in this patient group.

Left ventricular myocardial velocities in healthy children: quantitative assessment by tissue Doppler echocardiography and relation to the characteristics of filling of the left ventricle

AIM

To assess the myocardial velocities of the mitral annulus, left ventricular lateral wall, and midseptum in healthy children, and to compare these parameters with transmitral and pulmonary venous velocities.

METHODS AND RESULTS

We examined 72 children, half being male, who had no systemic or cardiac pathologies. Their mean age was 6.73 +/- 5.10 years, with a range from 0.1 to 17.75 years, and a median age of 6.71 years. Each parameter was measured twice, at end inspiration and end expiration. The tissue velocities are similar in males and females (p > 0.05). The longitudinal velocity of the heart in early diastole has a positive correlation with age (p < 0.05; midseptum velocity r = 0.57, left ventricular lateral wall velocity r = 0.56, mitral annulus velocity r = 0.56), and the tissue velocities are not influenced by respiration (p > 0.05). The myocardial velocities of different segments of the left ventricle are not correlated with the transmitral or pulmonary venous flows (p < 0.05). When age is controlled for heart rate, age mainly affects the systolic velocity of the mitral annulus and the early diastolic velocity of the midseptum in longitudinal axis, as well as the early diastolic velocity of the midseptum in transverse axis (p > 0.05 for all, r = 0.34, 0.29, 0.30 respectively).

CONCLUSION

This study, which has determined reference values for tissue velocities in a large healthy group of children, will now set the scene for further studies in children with heart disease.

Serum troponin T levels and echocardiographic evaluation in children treated with doxorubicin

OBJECTIVE

We investigated the usefulness of serum cardiac Troponin T (cTnT) to detect doxorubicin related cardiotoxicity as a non-invasive and reliable method.

PATIENTS AND METHODS

Twenty-four patients who received doxorubicin for their solid tumors at cumulative doses of 400 mg/m(2) or higher, between June 1982 and August 2000, were included in this study. None of them had clinical signs or symptoms of cardiotoxicity. The age range was 3-31 years (median 14), and male to female ratio was 14/10. The systolic and diastolic cardiac functions were evaluated by two-dimensional, M-mode, and Doppler echocardiography. Serum cTnT levels were measured by a third generation immunoassay method and the lowest detectable level was 0.010 ng/ml.

RESULTS

The cumulative doxorubicin doses were at the range of 400 and 840 mg/m(2) (median 480). The time past from the last doxorubicin dose was 1-168 months (median 12). All of the patients had normal chest X-rays, electrocardiograms, and nine patients (37.5%) had abnormal systolic or diastolic cardiac function parameters. The median cumulative doxorubicin doses of the patients with normal and abnormal echocardiographic parameters were 480 and 440 mg/m(2), respectively. Serum cTnT values of 21 patients were below the detection limit (< 0.010 ng/ml). There was no statistical difference between serum cTnT levels of the patients with normal and abnormal echocardiographic findings (P = 0.376).

CONCLUSIONS

No correlation was found between serum cTnT values, cumulative doxorubicin doses, and systolic or diastolic cardiac functions. We can conclude that echocardiographic follow-up is more reliable than serum cTnT levels for detecting subclinical cardiac toxicity.

Evaluation of subclinical valvar disease in patients with rheumatic fever

Carditis is the only manifestation of acute rheumatic fever that leads to permanent disability. Hence, its diagnosis is of paramount importance. Recently, it has been reported that Doppler echocardiography has disclosed subclinical valvar regurgitation in some patients with acute rheumatic fever manifested as isolated arthritis or pure chorea. The prognosis of such patients with acute rheumatic fever and subclinical valvitis is not clear. We aimed, therefore, prospectively to investigate the potential to diagnose patients with subclinical carditis. We examined 40 patients, aged from 7 to 16 years, with Doppler evidence of mitral and aortic regurgitation, but in the absence of any pathologic murmur. The major findings satisfying the Jones criterions were arthritis in 29 patients, chorea in 10 patients, and arthritis and erythema marginatum in one patient. Of the patients, 33 had mitral regurgitation, 6 patients had combined mitral and aortic regurgitation, and one patient had aortic regurgitation. The patients were followed over a mean period of 18.1 +/- 13.9 months, the valvar regurgitation disappearing in 23 (57.5%). No significant differences were observed in the resolution of the valvitis between those treated with acetylsalicylic acid, steroids, or those receiving no treatment. It is noteworthy, nonetheless, that patients treated with steroids were the fastest to recover from valvitis (p < 0.05). Based on our study, we suggest that subclinical valvitis demonstrated by echocardiography should now be accepted as adequate evidence for the diagnosis of carditis, and become a major diagnostic criterion for acute rheumatic fever. When managing this group of patients with subclinical disease, treatment with steroids seems to have a role in promoting early resolution of the valvitis.

Permanent form of junctional reciprocating tachycardia and tachycardia-induced cardiomyopathy treated by catheter ablation: a case report

The permanent form of junctional reciprocating tachycardia (PJRT) is usually refractory to drug therapy, and these patients are at risk of developing tachycardia-induced cardiomyopathy. The electrocardiogram insribes inverted P waves in leads 2, 3, aVF as well as left lateral leads, along with a P-R interval shorter than R-P interval during the tachycardia. This report describes a three-year-old male patient with PJRT who underwent successful radiofrequency catheter ablation (RFA) of accessory pathway. On transthoracic echocardiography of patient, decreased ventricular systolic function was observed. RFA was performed by applying radiofrequency pulses. Echocardiograms of the patient, two months after catheter ablation, demonstrated progressive improvement of ventricular function. Transcatheter radiofrequency ablation of accessory pathways in patients with PJRT is an effective, and possibly preferable, form of treatment, especially in cases of tachycardia refractory to multiple pharmacologic treatments or when left ventricular dysfunction is present.

A case of superoinferior ventricular heart with situs ambiguus, dextroventricular loop, and levo transposition of the arteries: prenatal and postnatal echocardiographic diagnosis

A unique case of superoinferior ventricles, left atrial isomerism, concordant atrioventricular connection, and discordant ventriculoarterial connection is described. The associated anomalies were azygous vein continuation, large subpulmonary and apical ventricular septal defects, and left ventricular outflow tract obstruction (pulmonary stenosis). The diagnosis was mostly made by fetal echocardiography and the superoinferior location of the ventricles was confirmed by postnatal echocardiography. Fetal and postnatal echocardiography facilitated the precise morphologic diagnosis and segmental analysis of this defect.

The Doppler echocardiographic assessment of valvular regurgitation in normal children

To determine the frequency of valvular regurgitation, 174 children from birth to 18 years old (mean age 7.42+/-4.54 years), with structurally normal hearts were analyzed. Flow patterns across the four valves were examined by pulsed- (PW), continuous-wave (CW) and color Doppler. Regurgitation was detected in 59.7% of the valves. Tricuspid regurgitation (TR) was most commonly found in 32.8% (n=57), pulmonary regurgitation (PR) in 17.2% (n=30), mitral regurgitation (MR) in 8.6% (n=15), and aortic regurgitation (AR) in 1.1% (n=2). The range of peak velocities of the regurgitant flow with CW were as follows: TR:0.98-2.54 m/sec, PR:0.50-1.80 m/sec, MR:0.72-2.30 m/sec, and AR:1.22-1.25 m/sec. The mean peak velocities of the regurgitant flow were similar with CW and PW measurements (p>0.05). The length of the regurgitant flow with color Doppler was less than 1 cm beyond the mitral and aortic valves. It reached up to 1.8 cm behind the pulmonary and 1.83 cm behind the tricuspid valves. Frequency of valvular regurgitation was unchanged with age (p>0.05). Tricuspid regurgitation was more frequent in males (40.9% versus 23.5%; p=0.016). Regurgitation of tricuspid, pulmonary or mitral valves is relatively common in children with structurally normal hearts. Aortic regurgitation is scarce and the possible pathologic cause should always be carefully sought.

Normal patterns of flow in the superior caval, hepatic and pulmonary veins as measured using Doppler echocardiography during childhood

To date, no reference values have been provided for right and left atrial filling in normal children. The aim of our study, therefore, was to characterize measurements of superior caval, hepatic, and pulmonary venous flow using Doppler echocardiography in a large group of normal children to reflect the effects of age, body mass index, sex, heart rate and respiration. Doppler echocardiographic examinations of the superior caval, hepatic and pulmonary veins were performed during inspiration and expiration in 72 healthy children with a mean age of 6.73 +/- 5.10 years. The subjects were segregated into four age groups, namely infants < 2 years, preschool children between the ages of 2 and 7 years, children of school age between 7 and 11 years, and adolescents older than 11 years. Age has significant effect on the systolic and reverse atrial flows within the superior caval vein (p < 0.05). No change in the Doppler velocities was observed related to body mass index or sex. All peak systolic velocities decreased significantly during expiration (p < 0.05). This decrease was most prominent in the hepatic vein (26%), but less remarkable in the superior caval vein (5.7%) and the pulmonary veins (3.9%). During expiration, the peak diastolic flow in the superior caval and the hepatic veins decreased, while the reverse atrial flow in the hepatic vein increased (p < 0.05). Pulmonary venous velocities were similar in all age groups (p > 0.05). Except for the systolic pulmonary venous velocities, these parameters were not influenced by respiration (p > 0.05). The diastolic time, the interval between reverse atrial flow and ventricular systole reflected by the R wave on the electrocardiogram, and the interval between ventricular systole and diastolic flow, were negatively correlated with heart rate (p < 0.05; r = -0.35, -0.85, and -0.8 respectively), and positively correlated with age (p < 0.05; r = 0.3, 0.8, and 0.7 respectively). They were not influenced by respiration. Our study provides data of the patterns and the normal ranges of velocities of superior caval, hepatic, and pulmonary venous flow in a series of normal children. The results can now be used for comparison with the patterns found in the setting of disease.

Reproducibility of the head-up tilt test results in children with vasovagal syncope

BACKGROUND

This prospective study aims to investigate the reproducibility of HUTT results in children with typical history of vasovagal syncope.

METHODS

Between October 1996 and October 1999, 58 children with a history of typical vasovagal syncope attacks were evaluated with head up tilt test (HUTT). The table was tilted to 60 degrees and the patients were monitored for heart rate and blood pressure changes during 45 min. No provocative agents were used. The test was repeated a week later at a similar setting.

RESULTS

Of 58 patients, 39 had positive and 19 had negative response during the initial test. During the second test, the positive response was reproduced in 29 cases (50%), and the negative response was reproduced in 16 cases (28%). Ten patients (17%) with an initial positive test had a negative second test. A negative test became positive only in three patients (5%). There were 12 vasodepressor, four cardioinhibitor and 23 mixed responses among the initial tests. Only in four patients did the type of the response change from vasodepressor to a mixed type during the second test. The reproducibility of a positive tilt test was 74.4% (29/39), the negative tilt test was 84.2% (16/19), and the overall reproducibility of the HUTT was 77.6% (45/58).

CONCLUSIONS

Unprovoked HUTT in children is reproducible when repeated on different days and similar settings and the results are comparable to the ones with adult patients.

Cardiac troponin T and myocardial injury during routine cardiac catheterisation in children

BACKGROUND

This study aims to investigate whether intracardiac catheterization produces myocardial damage on pediatric heart.

METHODS

Five blood samples were collected (basal, immediate post procedure, at 4, 12 and 24 h after the procedure) for troponin T and creatine kinase MB (CKMB) from 48 consecutive patients (age: 5.34+/-6.03 years). The effect of age, duration of procedure, pulmonary hypertension, cyanosis, and medication taken for congestive heart failure on the levels of troponin T and CKMB were sought.

RESULTS

The increase in CKMB (basal CKMB: 3.93+/-3.70 ng/ml; peak CKMB: 8.68+/-10.89 ng/ml; P<0.0001) and troponin levels (basal troponin: 0.002+/-0.003 ng/ml; peak troponin: 0.11+/-0.23 ng/ml; P<0.0001) over time was significant in the study group. Additionally younger patients (</=1 year), patients with pulmonary hypertension (mean pulmonary artery pressure >25 mmHg), longer procedure time (>30 min), and patients taking anti-congestive heart failure therapy had significantly higher levels of CKMB and troponin (P>0.05).

CONCLUSION

All patients undergoing cardiac catheterization are under risk of myocardial injury, and younger patients with pulmonary hypertension and especially with compensated cardiac failure have increased risk of myocardial damage, and need to be handled carefully.

Noncompaction of ventricular myocardium: a study of twelve patients

We report 12 patients with ventricular noncompaction who were echocardiographically identified at our institution since 1991. The mean age at presentation was 3.5 years. Five patients had isolated noncompaction. Three of them had subnormal left ventricular systolic function at presentation. Noncompaction was associated with complex congenital heart defect in 3 patients. Four patients had simple congenital heart defects: pulmonary stenosis, coarctation of aorta with aberrant origin of right subclavian artery, ventricular septal defect, and partial anomalous pulmonary venous return. The observed rhythm abnormalities were Wolff-Parkinson-White syndrome and paroxysmal supraventricular tachycardia, bigemini ventricular extrasystoles, and left bundle branch block. A transvenous pacemaker was implanted in a patient because of complete heart block. Noncompaction of the ventricular myocardium is rare. Our patients clearly represent the clinical and morphological spectrum of this disorder. Distinct morphological features can be diagnosed on 2-dimensional echocardiography.

Heart rate variability and autonomic nervous system changes in children with vasovagal syncope

The aim of this study was to evaluate the HRV at rest and during tilt test (HUTT) in children with a history of vasovagal syncope and to link the HRV indices with the clinical results of the test. HRV indices were assessed in the supine position and during the initial 5 minutes of the 60-degree HUTT in 49 patients (33 females, 16 males, mean age of 13 +/- 2.8 years) who were evaluated for recurrent syncope. The positive to negative results of the test were 21 to 28. The normalized power of high frequency component (npHF) decreased, normalized power of low frequency component (npLF) and the LF:HF ratio increased during HUTT of tilt-positive patients (P < 0.05 for each parameter). Parallel changes, but to a lesser degree, were observed for similar HRV parameters of tilt-negative patients. In addition, the HF and all the time-domain indices decreased significantly (P < or = 0.05) during HUTT in the latter group. When the tilt-positive and -negative patients were compared, the npHF was lower (P = 0.002), npLF and LF:HF ratio were higher (P = 0.01 and P = 0.001, respectively) during the test in tilt-positive patients, reflecting increased sympathetic tone in this group. A cut-off point for LF:HF was assigned as 2.7 for differentiating tilt-negative and tilt-positive results. The specificity, sensitivity, and positive and negative predictive values of this cut-off point were calculated as 93%, 52%, 85%, and 41%, respectively. Patients with vasovagal syncope show variations in vagal autonomic tone and appear to be more prone to syncope when their sympathetic tone is elevated at the beginning of the test. LF:HF > 2.7 is a specific marker (specificity 93%) and can correctly predict a positive tilt test in 85% of patients.

Dysrhythmia as a cause of syncope in children without neurological or cardiac morphological abnormalities

BACKGROUND

Arrhythmias are among the malignant causes of syncope. This study has been undertaken to determine the relative incidence and significance of dysrhythmia in the pathogenesis of syncope among patients referred to a pediatric cardiology unit.

METHODS

Between March 1997 and March 1999, 105 consecutive patients (59 female, 46 male) aged 11.5 +/- 3.6 years without neurologic or cardiac morphologic causes were evaluated for at least one episode of syncope. A pediatric cardiologist and a pediatric neurologist evaluated all the patients. Routine chest X-ray, 12-lead electrocardiogram (ECG), electroencephalography (EEG), 24-h Holter monitoring and echocardiography were carried out. When deemed necessary, further tests were undertaken for the cases of syncope which were unexplained by routine tests.

RESULT

The cause of syncope was identified as vasovagal in 25.7% (n = 27) and related to dysrhythmia in 30.5% (n = 32). The cause was migraine-associated syncope in two children, psychogenic syncope in three children and orthostatic hypotension in one patient. The cause was unknown in 36.2% (n = 38).

CONCLUSION

We conclude that dysrhythmia is a significant and frequent cause in children referred to pediatric cardiology units. The combination of ECG, Holter monitoring, electrophysiologic study, transtelephonic ECG and head-up tilt test can identify the underlying cause of syncope in as many as 58% of these patients that present with syncope.

A case of severe Ebstein's anomaly with incompetent pulmonary valve

A case of Ebstein's anomaly with functional pulmonary atresia diagnosed in utero is presented. The diagnosis was confirmed by postnatal echocardiographic, angiographic, and postmortem pathologic findings. On echocardiography the septal leaflet of the tricuspid valve was displaced towards the right ventricular apex. The tricuspid valve was moderately regurgitant and the arterial duct was patent. Continuous wave or color Doppler revealed serious reduction in forward flow from right ventricle through the pulmonary arteries; however, massive pulmonary regurgitation was observed. Pulmonary circulation was dependent on the ductal flow due to functional pulmonary atresia. Angiography revealed the massively enlarged right atrium, the absence of forward flow through the tricuspid valve, transfer of contrast material through the atrial septal defect to the left atrium, and the retrograde inflow of the pulmonary arteries from the aorta via the patent arterial duct. Ebstein's anomaly accompanied by functional pulmonary atresia is very rare. The fetal and neonatal presentation of this anomaly is associated with poor outcome.

Complications and outcome in left-sided endocarditis in children

We retrospectively assessed the clinical course and outcome of left-sided endocarditis in pediatric patients to find out the prognostic significance of the presence and size of echocardiographically detected vegetations. Among the children admitted to our institution with endocarditis between January 1987 and October 1999, 16 patients (mean age 9.03 +/- 4.95 years) who met the Duke criteria for the diagnosis of infective endocarditis (IE) were included in this study. Rheumatic valvular disease was the most frequent underlying heart disease (10 patients: 62.5%). Five patients were operated at a mean of 13.9 months before endocarditis, and all had residual defects. Vegetation was detected in 11 cases (69%). Ten patients had major complications (within 2 weeks in 6 patients). Three patients developed congestive heart failure (CHF), six had intracranial and one had lower extremity emboli. Among them four were operated because of complications (CHF: 3 cases, intracranial emboli: 1 case). All the operated cases are doing well. The association between intracranial embolic events and echocardiographically detected vegetations was determined by calculating specificity (40%), sensitivity (100%), positive predictive value (50%), and negative predictive value (100%). No intracranial embolism occurred in patients without vegetations. All vegetations were < or = 6 mm in patients with systemic embolism. There were four deaths, three of which were because of intracranial embolism. This study suggests that intracranial emboli have a major risk of mortality in left-sided endocarditis. The larger size of the vegetation is not a predictor of complications; furthermore, the absence of vegetations predicts that the patient is safe from embolic events. Therefore all patients with left-sided IE should be considered for earlier surgical intervention.

Sotalol in treatment of pediatric cardiac arrhythmias

BACKGROUND

There is limited experience on sotalol use in the management of childhood arrhythmias. This study reviews the results of our experience with oral sotalol for treatment and prevention of tachyarrhythmias in children.

METHODS

The records of 62 patients (27 female, 35 male, mean age: 8.5+/-5.3 years) treated with sotalol for supraventricular or ventricular arrhythmias from 1994 to 1999 at our institution were reviewed. Demographic, clinical, echocardiographic, electrocardiographic (ECG), ambulatory ECG and electrophysiologic variables were collected.

RESULTS

Forty-two (63.6%) patients had re-entrant supraventricular tachycardia, eight patients (12.9%) had atrial tachycardia, one patient (1.6%) had junctional ectopic tachycardia, four patients (6.5%) had ventricular tachycardia, and seven patients (11.3%) had complex ventricular arrhythmias, as evidenced by surface or ambulatory ECG records; or revealed during the electrophysiological study. The mean sotalol dose was 3.9+/-1.2 mg/kg per day. In 15.5+/-13.9 months of sotalol use 50% (n=31) had complete relief of symptoms and/or arrhythmia and 29% (n=18) had partial relief. Sotalol was ineffective in 20% (n=13). Sotalol was more effective in re-entrant type supraventricular tachycardias (P=0.012). Sotalol was the first choice in 35.5% of patients. The sotalol therapy was initiated in inpatient settings in 40.3% (25 patients). Complications due to sotalol were seen in six patients (five patients developed bradycardia/pauses, and one patient had torsades de pointes) for which the sotalol dose was modified. In patients with sick sinus syndrome, a pacemaker was implanted and in another patient sotalol was stopped.

CONCLUSION

Sotalol, being an effective and safe drug particularly in children, is a good therapeutic alternative for the preventive treatment of childhood tachyarrhythmias.