Acquired von Willebrand syndrome in congenital heart disease surgery: results from an observational case-series

Essentials Bleeding complications during congenital heart disease surgery in neonatal age are very common. We report the perioperative incidence of acquired von Willebrand syndrome (aVWS) in 12 infants. aVWS was detected in 8 out of 12 neonates and infants intraoperatively after cardiopulmonary bypass. Ten patients received von Willebrand factor concentrate intraoperatively and tolerated it well. SUMMARY: Background Cardiac surgery of the newborn and infant with complex congenital heart disease (CHD) is associated with a high rate of intraoperative bleeding complications. CHD-related anatomic features such as valve stenoses or patent arterial ducts can lead to enhanced shear stress in the blood stream and thus cause acquired von Willebrand syndrome (aVWS). Objective To evaluate the intraoperative incidence and impact of aVWS after cardiopulmonary bypass (CPB) in neonates and infants with complex CHD. Patients/Methods We conducted a survey of patients aged < 12 months undergoing complex cardiac surgery in our tertiary referral center. Twelve patients, whose blood samples were analyzed for aVWS before CPB and immediately after discontinuation of CPB on a routine basis, were eligible for the analysis. von Willebrand factor antigen (VWF:Ag), ristocetin cofactor activity (VWF:RCo), collagen binding activity (VWF:CB), VWF:multimers and factor VIII activity (FVIII:C) were determined. Results aVWS was diagnosed by VWF multimer analysis in 10 out of 12 patients (83%) prior to surgery and intraoperatively at the end of CPB in 8 out of 12 patients (66%). Ten patients received VWF/FVIII concentrate intraoperatively as individual treatment attempts during uncontrolled bleeding. They tolerated it well without intraoperative thrombotic events. One patient suffered a transient postoperative cerebral sinuous vein thrombosis. Conclusions aVWS is of underestimated incidence in complex CHD surgery. These data may offer a new approach to reduce the risk of severe bleedings and to achieve hemostasis during high-risk pediatric cardiac surgery by tailoring the substitution with von Willebrand factor concentrate.

Pitfalls in Echocardiography: Coarctation of the Aorta Presenting as Dilated Cardiomyopathy (DCM)

Purpose: The morphologic spectrum of aortic coarctation extends from discrete isthmic obstruction to tubular hypoplasia of the entire aortic arch. Neonates with coarctation frequently present with congestive heart failure and critically reduced perfusion of the descending aorta following ductal closure. During the recent years we observed several infants with coarctation who presented beyond the neonatal period with dilated cardiomyopathy (DCM). We reviewed our patients with coarctation to determine whether this presentation represents an exception or is relevant for the differential diagnosis of children with DCM. Materials and Methods: From 1/2001 to 12/2013 74 babies with isolated coarctation were diagnosed in our institution. 50 patients presented in the neonatal period and 24 patients beyond the first month. Results: 5/74 infants presented after the neonatal period with poorly contractile, dilated left ventricles. Echocardiographic detection of the coarctation was facilitated by application of the ductal view and by Doppler interrogation of the celiac artery revealing a significantly diminished systolic flow velocity. All patients underwent resection of the coarctation and end-to-end anastomosis of the aorta. Postoperative normalization of left ventricular function was observed within a median interval of 2 months. Conclusion: Coarctation of the aorta presenting as DCM accounted for 21 % of our infants with coarctation who presented beyond the neonatal period and 7 % of those in the first year of life. The stenosis was difficult to detect because of its distal location and normal configuration of the aortic arch. Isthmic coarctation should be included in the differential diagnosis of infants with DCM and requires careful examination of the isthmic region in these children.

Severe chest pain caused by Mycoplasma myocarditis in an adolescent patient

Intermittent chest pain is a common symptom in adolescent patients, which can be attributed to musculoskeletal disorders in the majority of cases. While most patients have a benign course of their pain episodes, the differential diagnosis includes diseases which are associated with serious and even life-threatening complications. Therefore, careful examination and systematic diagnostic evaluation is important. We report on an adolescent, who presented with severe chest pain and distinct electrocardiographic findings caused by Mycoplasma pneumoniae myocarditis.

Factor X deficiency and intracranial bleeding: who is at risk?

Very few mutations of the gene encoding for coagulation factor X (FX) have been found associated with intracranial haemorrhage (ICH) due to FX deficiency (FXD). No guidelines exist as to when prophylaxis in FXD should be started and how patients at risk for ICH can be identified. We report on a novel mutation causative for ICH in a family of Iranian origin and provide a summary of all published mutations in the FX gene related to ICH. The index patient is an infant with umbilical bleeding requiring blood transfusion in the postnatal period. The international normalized ratio (6.01) and activated partial thromboplastin time (117 s) were prolonged. Coagulation factor analysis was normal except for FX activity (<1%). At 4 months, the child suffered a spontaneous severe intracranial haemorrhage. The child was the product of a consanguineous union. Four of five available family members from three generations displayed minor bleeding symptoms and mildly reduced FX. Sequencing of FX gene demonstrated homozygosity for a novel duplication A (c.1402_1403dupA)* in exon 8 and heterozygosity in four family members. We compare this case to all 15 patients with FXD and ICH and their 11 known mutations described so far. This case illustrates a pattern of FXD (a male neonate with umbilical or gastrointestinal bleeding, very low FX:C (<1%) and an underlying homozygous genotype) who may be at high risk for ICH. In these cases, we recommend to start early prophylactic substitution of FX to prevent a possible life-threatening haemorrhage.

Neonatal Marfan syndrome: unusually large deletion of exons 24-26 of FBN1 associated with poor prognosis

Neonatal Marfan syndrome is a very rare subset of the classical Marfan syndrome with pronounced phenotypic expression especially of the cardiovascular manifestations. It is associated with a very poor prognosis, with approximately 50% of affected infants dying from cardiac failure during the first year of life. We present a newborn with the classical phenotype of neonatal Marfan syndrome. Within few hours after birth, progressive and refractory heart failure developed. Postmortal molecular study revealed an unusually large deletion of exons 24-26 within the so-called neonatal region of the gene FBN1, which might explain the unfavourable course of the disease in our patient.

Transarterial and transvenous approach for transcatheter closure of a large coronary artery fistula with the Amplatzer vascular plug

Interventional occlusion of coronary artery fistulas has become a well-accepted alternative to surgical therapy. However, occlusion of high-flow lesions in children, necessitating implantation of large occluding devices, may be limited by the requirement of large delivery catheters. This report describes the interventional occlusion of a large coronary artery fistula in an 8-year-old girl. Complete occlusion was achieved by subsequent transvenous and transarterial implantation of two Amplatzer vascular plugs (AVP). The AVP is an interesting alternative for interventional occlusion of large coronary artery fistulas in children that can be deployed safely by rather small guiding catheters.

The Wada test in Austrian, Dutch, German, and Swiss epilepsy centers from 2000 to 2005: a review of 1421 procedures

Twenty-six Austrian, Dutch, German, and Swiss epilepsy centers were asked to report on use of the Wada test (intracarotid amobarbital procedure, IAP) from 2000 to 2005 and to give their opinion regarding its role in the presurgical diagnosis of epilepsy. Sixteen of the 23 centers providing information had performed 1421 Wada tests, predominantly the classic bilateral procedure (73%). A slight nonsignificant decrease over time in Wada test frequency, despite slightly increasing numbers of resective procedures, could be observed. Complication rates were relatively low (1.09%; 0.36% with permanent deficit). Test protocols were similar even though no universal standard protocol exists. Clinicians rated the Wada test as having good reliability and validity for language determination, whereas they questioned its reliability and validity for memory lateralization. Several noninvasive functional imaging techniques are already in use. However, clinicians currently do not want to rely solely on noninvasive functional imaging in all patients.

[A life-threatening cardiomyopathy following port-a-cath infection under immune tolerance therapy]

The development of inhibitors in patients with severe haemophilia A is a serious complication requiring long term immune tolerance therapy (ITT). ITT frequently requires implantable central venous access, mostly port catheters. Their use may be complicated by thrombosis and infection. We report on an 18 year old patient with severe haemophilia A who had developed a high-titre factor VIII inhibitor in the age of five years. ITT required the implantation of a port system. The postoperative course was complicated by severe septicaemia with congestive cardiac failure. The port catheter was removed due to recurrent fever after 26 days. Our patient developed dilative cardiomyopathy. ITT had to be stopped and was replaced by on demand therapy with an activated prothrombin complex concentrate. Cardiomyopathy resulted in congestive heart failure, severe ventricular arrhythmias and the death of the young man. In patients with haemophilia, dilative cardiomyopathy and development of inhibitors the possibility of cardiac transplantation should be evaluated before increasing inhibitors and the development of pulmonary hypertension exclude this therapeutical option.

Septischer Schock mit Niereninsuffizienz und Hautmanifestationen als Komplikation einer Salmonella-enteritidis-Infektion

Infections by Salmonella enteritidis commonly present with diarrhoea, vomiting and fever and complications such as septicaemia, pleural effusion and acute renal failure are usually rare. There are only few reports of cutaneous manifestations and especially septic shock in patients with Salmonella enteritidis infection. We report on a previously healthy seven-year-old boy suffering from Salmonella enteritidis septicaemia presenting with septic shock, pleural effusion, renal failure and an unusual maculopapular skin eruption on both wrists and ankles. The boy had no underlying immunodeficiency.

Lebensbedrohliche Kardiomyopathie als Folge einer Portkatheterinfektion bei Immuntoleranztherapie

Bei Patienten mit schwerer Hämophilie A stellt die Entwicklung von Inhibitoren eine ernsthafte Komplikation dar, die einer lange dauernden Immuntoleranztherapie (ITT) bedarf. Sie wird meist über Portkatheter durchgeführt. Zu den häufigsten Komplikationen zählen Thrombosen und Infektionen. Wir berichten über einen 18-jährigen Patienten mit schwerer Hämophilie A, der im Alter von fünf Jahren einen hochtitrigen Faktor-VIII-Inhibitor entwickelt hatte. Die folgende ITT erforderte die Implantation eines Portkatheters. Postoperativ kam es zu einer schweren Sepsis mit Herzinsuffizienz. Der Katheter wurde am 26. postoperativen Tag entfernt. Der Patient entwickelte eine dilatative Kardiomyopathie. Die ITT musste beendet und auf eine Bedarfsbehandlung mit einem Prothrombinkomplexkonzentrat umgestellt werden. Die Kardiomyopathie verschlechterte sich allmählich und führte durch unkontrollierbare ventrikuläre Arrhythmien zum Tod des Patienten. Die Frage einer Herztransplantation sollte bei Patienten mit Hämophilie, Kardiomyopathie und Hemmkörpern frühzeitig evaluiert werden, bevor steigende Hemmkörpertiter oder die Entwicklung einer pulmonalen Widerstandserhöhung diese Behandlungsoption verhindern.

Leukoencephalopathy with ataxia, hypodontia, and hypomyelination

The authors describe four unrelated girls with a distinctive neurologic disorder with early-onset progressive ataxia and hypodontia with a characteristic pattern of delayed dentition. Cerebral MRI shows hypomyelinated white matter and cerebellar atrophy; 1H-MRS of white matter reveals a marked elevation of myo-inositol.

Activating Ly-49D NK receptors: expression and function in relation to ontogeny and Ly-49 inhibitor receptors

Developmental changes in the repertoire of activating Ly-49 family members have not been examined previously. In the present study, we have examined the expression and function of the activating Ly-49s (D and H) from birth through 8 weeks of age. We demonstrate that 1) activating Ly-49s are expressed early, 2) their expression intensity is not different from adult NK cells, and 3) activating receptors are functional. Examination of the inhibitory Ly-49s also demonstrated functional capacity immediately upon expression. To examine the kinetics of expression of the repertoire of activating Ly-49 members, we utilized five- and six-color flow cytometric analyses of NK cells from birth through adulthood. Previous studies examining the inhibitory Ly-49 repertoire have proposed that expression is regulated by the product rule. Our results indicated that Ly-49D, which recognizes H-2Dd, had a discordantly high coexpression of the inhibitory Ly-49s that recognized H-2Dd (Ly-49A and Ly-49G2). The product rule of Ly-49 expression does not explain the coexpression of selected activating and inhibitory receptors. This high level of coexpression of H-2Dd recognizing activating and inhibitory Ly-49s suggests an in vivo selection or regulated coexpression.