Childhood Obesity and Congenital Heart Disease: A Lifelong Struggle

Congenital heart disease (CHD) affects approximately one in every one hundred infants worldwide, making it one of the most prevalent birth abnormalities globally. Despite advances in medical technology and treatment choices, CHD remains a significant health issue and necessitates specialized care throughout an individual's life. Childhood obesity has emerged as a novel global epidemic, becoming a major public health issue, particularly in individuals with lifelong conditions such as CHD. Obesity has profound effects on cardiac hemodynamics and morphology, emphasizing the importance of addressing obesity as a significant risk factor for cardiovascular health. Obesity-induced alterations in cardiac function can have significant implications for cardiovascular health and may contribute to the increased risk of heart-related complications in obese individuals. Moreover, while diastolic dysfunction may be less apparent in obese children compared to adults, certain parameters do indicate changes in early left ventricular relaxation, suggesting that obesity can cause cardiac dysfunction even in pediatric populations. As most children with CHD now survive into adulthood, there is also concern about environmental and behavioral health risk factors in this particular patient group. Addressing obesity in individuals with CHD is essential to optimize their cardiovascular health and overall quality of life. This review aims to succinctly present the data on the impact of obesity on CHD and to enhance awareness of this perilous association among patients, families, and healthcare providers.

Mid- and Long-Term Atrio-Ventricular Functional Changes in Children after Recovery from COVID-19

Background: Although most children may experience mild to moderate symptoms and do not require hospitalization, there are little data on cardiac involvement in COVID-19. However, cardiac involvement is accurately demonstrated in children with MISC. The objective of this study was to evaluate cardiac mechanics in previously healthy children who recovered from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in a long-term follow-up by means of two-dimensional speckle-tracking echocardiography (STE). Methods: We analyzed a cohort of 157 paediatric patients, mean age 7.7 ± 4.5 years (age range 0.3−18 years), who had a laboratory-confirmed diagnosis of SARS-CoV-2 infection and were asymptomatic or mildly symptomatic for COVID-19. Patients underwent a standard transthoracic echocardiogram and STE at an average time of 148 ± 68 days after diagnosis and were divided in three follow-up groups (<180 days, 180−240 days, >240 days). Patients were compared with 107 (41 females—38%) age- and BSA-comparable healthy controls (CTRL). Results: Left ventricular (LV) global longitudinal strain (post-COVID-19: −20.5 ± 2.9%; CTRL: −21.8 ± 1.7%; p < 0.001) was significantly reduced in cases compared with CTRLs. No significant differences were seen among the three follow-up groups (p = NS). Moreover, regional longitudinal strain was significantly reduced in LV apical-wall segments of children with disease onset during the second wave of the COVID-19 pandemic compared to the first wave (second wave: −20.2 ± 2.6%; first wave: −21.2 ± 3.4%; p = 0.048). Finally, peak left atrial systolic strain was within the normal range in the post-COVID-19 group with no significant differences compared to CTRLs. Conclusions: Our study demonstrated for the first time the persistence of LV myocardial deformation abnormalities in previously healthy children with an asymptomatic or mildly symptomatic (WHO stages 0 or 1) COVID-19 course after an average follow-up of 148 ± 68 days. A more significant involvement was found in children affected during the second wave. These findings imply that subclinical LV dysfunction may also be a typical characteristic of COVID-19 infection in children and are concerning given the predictive value of LV longitudinal strain in the general population.

969 MID AND LONG TERM ATRIO-VENTRICULAR MECHANISM IN CHILDREN AFTER RECOVERY FROM ASYMPTOMATIC O MILDLY SYMPTOMATIC SARS COV2 INFECTION

Background

Clinical manifestations of children's coronavirus disease-2019 (COVID-19) were initially considered less severe compared with adult patients. However, there is now increasing evidence of a “long-tail” of COVID-19 related symptoms lasting for several months after recovery from the acute infection. Long COVID-19-related symptoms and mechanisms are poorly characterized and understood, with several phenotypes reported, often driven by long-term tissue damage (such as lung, heart and brain) and pathological inflammation due to viral persistence and/or immune deregulation.

Purpose

The objective of this study was to evaluate atrio-ventricular mechanics, by means of two-dimensional speckle-tracking echocardiography, in previously healthy children recovered from asymptomatic or mildly symptomatic severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in a long-term follow-up.

Methods

We analysed a cohort of 157 paediatric patients, mean age 7 ± 4 years, who had a confirmed diagnosis of SARS-CoV-2 infection and were asymptomatic or mildly symptomatic for COVID-19. Patients underwent standard transthoracic echocardiogram and speckle tracking echocardiographic study 148 ± 68 days after diagnosis. One hundred seven age, sex, and body surface area comparable healthy subjects were used as control group.

Results

Left ventricular ejection fraction was within normal limits in postCOVID-19 cases and CTRL with no significant differences between the two groups (postCOVID-19: 65.6 ± 4% vs CTRL: 65.0 ± 5%, p = 0.182).Left ventricular (LV) global longitudinal strain (postCOVID-19: -20.5 ± 2.9%; CTRL: -21.8 ± 1.7%; p &lt; 0.001) was significantly reduced in cases compared with CTRLs. An amount of 11 (7%) postCOVID-19 cases showed impaired GLS values &lt; -17% and 95 subjects (60%) presented with a strain lower than -16% in more than 2 segments. These subjects did not show any difference regarding symptoms or serological findings. Moreover, GLS was significantly reduced in children with disease's onset during the second wave of COVID-19 pandemic, compared with those during the first wave (second wave: -20.2 ± 2.6%; first wave: -21.2 ± 3.4%; p = 0.048). Finally, peak left atrial systolic strain was within the normal range in the postCOVID-19 group with no significant differences compared to CTRL (postCOVID-19: 49.1 ± 12%; CTRL: 49.5 ± 18%).

Conclusions

SARS-CoV-2 infection may affect left ventricular deformation in children despite an asymptomatic or only mildly symptomatic acute illness. Our data show an amount of 60% of children, recovering from asymptomatic or mildly symptomatic COVID-19, with still mild subclinical systolic cardiac impairment in the mid- and long-term follow-up after the infection. This subtle impairment was seen to be worse in children recovering from the second wave of COVID-19 compared to the first one.

A follow-up is needed to verify the reversibility of these alterations and their impact on long-term outcomes.

1115 NON-INVASIVE MYOCARDIAL WORK INDICES IN PATIENTS WITH FONTAN CIRCULATION

Background

Although the Fontan operation has contributed greatly to the improvement of survival in patients with a single ventricle, cardiac function and exercise capacity may deteriorate over time. However, there have been no quantitative analyses of the effects of Fontan circulation on myocardial work (MW).

Recently, a novel non-invasive method for calculating MW has been introduced on the basis of speckle tracking analysis with the estimation of left ventricular (LV) pressure from brachial artery cuff pressure.

Purpose

Aim of this study was to evaluate the diagnostic performance of the non-invasive myocardial work indices in predicting subclinical myocardial work impairment in Fontan patients.

Methods

A total of 69 patients were included and compared with healthy age- and sex- matched controls (CTRL).

Ventricular systolic function and global longitudinal strain (GLS) were assessed. Cardiopulmonary exercise test was performed. Global myocardial work index (MWI) was calculated as the area of the LV pressure strain loops. From MWI, global constructive work (MCW), wasted work (MWW) and work efficiency (MWE) were estimated.

Results

The two groups were comparable for blood pressure, weight and height. Mean age of Fontan patients was 21.0±9.2 years. MWI (1162 ± 364 mmHg% vs 1777 ± 240 mmHg%, p &lt; 0.001), MCW (1554 ± 450 mmHg% vs 2102 ± 221 mmHg%, p = 0.001) and MWE (90 ± 6% vs 96 ± 2% p = 0.001) were significantly reduced in Fontan patients compared with healthy CTRL. Moreover, GLS (-13,9 ± 3,1% vs -21,2 ± 1.5%, p &lt; 0.001) and the ejection fraction (EF) (58,9 ± 4.5% vs 63.3 ± 3.9%, p &lt; 0.002) were significantly lower in Fontan patients. Fontan patients with normal EF showed, however, significantly reduced values of MWI compared with CTRL (p&lt;0.05).

Fontan patients with functional right ventricle showed significantly reduced MWE compared with patients with functional left ventricle (p=0.030).

In univariate analysis, peak VO2 was significantly associated with age, SatO2, MWI. In multivariate regression, lower peak VO2 was associated with older age (p = 0.003) and lower MWI (p = 0.026).

Conclusions

Fontan physiology is associated with disadvantageous ventricular work. In Fontan patients, estimation of MWI may be a more sensitive indicator of myocardial work impairment compared with EF and is able to predict exercise capacity.

966 ADVANCED ECHOCARDIOGRAPHIC AND CMR FEATURES OF PATIENTS WITH REPAIRED TETRALOGY OF FALLOT IN THE LONG-TERM FOLLOW-UP

Advanced echocardiographic and CMR features of patients with repaired Tetralogy of Fallot in the long-term follow-up.

Anna Gozzi1, Jolanda Sabatino1, Elena Cuppini1, Irene Cattapan1, Alessia Basso1, Jennifer Fumanelli1, Angela Di Candia1, Martina Avesani1, Domenico Sirico1, Biagio Castaldi1, Elena Reffo1, Alessia Cerutti1, Roberta Biffanti1, Giovanni Di Salvo1

1Department for Women's and Children's Health, University Hospital of Padova, Pediatric and Congenital Cardiology Unit, Via Nicolo` Giustiniani, 2, 35128 Padova, Italy

Background

Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease and the population of ToF repair survivors is growing rapidly. Children and, more frequently young adults, with repaired ToF develop late complications. Sudden cardiac death and life-threatening ventricular arrhythmia remain a concern in patients with repaired tetralogy of Fallot.

The aim of this study was to describe and analyse advanced echocardiographic and CMR features of patients with repaired ToF in the long-term follow-up and to find non-invasive predictors of adverse prognosis.

Methods

This is a retrospective cohort study. Consecutive 200 patients with repaired ToF who did not undergo pulmonary valve replacement were included. Mean age of all patients was 19 ± 8. The electrocardiographic (ECG), cardiopulmonary exercise testing (CPET), echocardiographic and cardiac magnetic resonance (CMR) data were reviewed retrospectively. Right myocardial work index (RWI) was calculated as the area of the right ventricular pressure strain loops. From RWI, Right Constructive Work (RCW), Wasted Work (RWW) and Work Efficiency (RWE) were estimated.

Patients were screened according the age at surgery (&lt;12 months and &gt;12 months) and the time since the repair (&lt; 25 years and ≥ 25 years).

A composite end-point of major adverse cardiovascular events (sudden cardiac death, sustained and non-sustained ventricular tachycardia, resuscitated sudden cardiac death, or syncope) was used.

Results

CPET values were not significantly different in patients with more than 25 years since the corrective surgery. Left ventricular ejection fraction measured either by CMR or echocardiography were slightly but significantly reduced in patients with more than 25 years since the corrective surgery.

Patients with older age at surgery (&gt;12 months) have significantly reduced V02max at CPET, larger RA and LA areas and larger RV basal diameter.

During a median follow-up of 2.9 years, 1 patient died suddenly, 5 had documented ventricular tachycardia, and other 4 had syncope. On univariate analysis, echocardiographic left atrial area/BSA (P=0.044) and right ventricular longitudinal strain (P=0.010) were significantly related to the combined end point. Patients with reported VT at Holter ECG presented significantly reduced right ventricular function in terms of CMR-EF, echocardiographic FAC and RWI.

Finally, TOF patients with borderline/impaired predicted VO2 max at CPET presented with significantly reduced RV freewall longitudinal strain and right ventricular myocardial work index.

Conclusion

Long-term survival and clinical condition after surgical correction of ToF in infancy is generally good and the late functional status in ToF - operated patients could be excellent up to 25 years after the repair. However, patients with older age at surgery have relative reduced functional status compared with those undergoing early repair. The echocardiographic and CMR evaluation of RV function are usually related to worse prognosis, recurrency of VT and reduced functional status in patients with repaired TOF.

Right ventricular myocardial work index is feasible in patients with repaired TOF; disadvantageous right ventricular work may be a more sensitive indicator of right ventricular impairment compared with standard echocardiographic parameters, and is able to predict exercise capacity.

Mid- and long-term atrio-ventricular mechanics in children after recovery from asymptomatic or mildly symptomatic SARS-CoV-2 infection

Background

Clinical manifestations of children's coronavirus disease-2019 (COVID-19) were initially considered less severe compared with adult patients. However, there is now increasing evidence of a “long-tail” of COVID-19 related symptoms lasting for several months after recovery from the acute infection. Long COVID-19-related symptoms and mechanisms are poorly characterized and understood, with several phenotypes reported, often driven by long-term tissue damage (such as lung, heart and brain) and pathological inflammation due to viral persistence and/or immune deregulation.

Purpose

The objective of this study was to evaluate atrio-ventricular mechanics, by means of two-dimensional speckle-tracking echocardiography, in previously healthy children recovered from asymptomatic or mildly symptomatic severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in a long-term follow-up.

Methods

We analysed a cohort of 157 paediatric patients, mean age 7±4 years, who had a confirmed diagnosis of SARS-CoV-2 infection and were asymptomatic or mildly symptomatic for COVID-19. Patients underwent standard transthoracic echocardiogram and speckle tracking echocardiographic study 148±68 days after diagnosis. One hundred seven age, sex, and body surface area comparable healthy subjects were used as control group.

Results

Left ventricular ejection fraction was within normal limits in postCOVID-19 cases and CTRL with no significant differences between the two groups (postCOVID-19: 65.6±4% vs CTRL: 65.0±5%, p=0.182).

Left ventricular (LV) global longitudinal strain (postCOVID-19: −20.5±2.9%; CTRL: −21.8±1.7%; p<0.001) was significantly reduced in cases compared with CTRLs. An amount of 11 (7%) postCOVID-19 cases showed impaired GLS values < −17% and 95 subjects (60%) presented with a strain lower than −16% in more than 2 segments. These subjects did not show any difference regarding symptoms or serological findings. Moreover, GLS was significantly reduced in children with disease's onset during the second wave of COVID-19 pandemic, compared with those during the first wave (second wave: −20.2±2.6%; first wave: −21.2±3.4%; p=0.048). Finally, peak left atrial systolic strain was within the normal range in the postCOVID-19 group with no significant differences compared to CTRL (postCOVID-19: 49.1±12%; CTRL: 49.5±18%).

Conclusions

SARS-CoV-2 infection may affect left ventricular deformation in children despite an asymptomatic or only mildly symptomatic acute illness. Our data show an amount of 60% of children, recovering from asymptomatic or mildly symptomatic COVID-19, with still mild subclinical systolic cardiac impairment in the mid- and long-term follow-up after the infection. This subtle impairment was seen to be worse in children recovering from the second wave of COVID-19 compared to the first one.

A follow-up is needed to verify the reversibility of these alterations and their impact on long-term outcomes.

Funding Acknowledgement

Type of funding sources: None.

The impact of dominant ventricle morphology and accessory ventricle size on clinical outcomes after Fontan procedure

Objectives

the physio-pathological role of the morphological ventricular dominance (left, FSLV; right, FSRV), and the hemodynamic contribute of an accessory ventricular chamber (AVC), in patients with functional single ventricle (FSV) after Fontan operation are still uncertain due to conflicting data. We analyzed a cohort of Fontan patients to assess and correlate such anatomical features to late clinical outcomes.

Methods

We enrolled all patients after a Fontan procedure who underwent a cardiac magnetic resonance (CMR) and a cardiopulmonary exercise test (CPET) in the previous 3 years. Clinical, CMR and CPET data from the last follow-up visit were retrieved to analyze whether the size of any AVC and the morphological ventricular dominance (FSLV vs FSRV) were correlated with clinical outcomes (NYHA, need for reinterventions or cardiac transplantation, mortality, arrhythmias, liver disease and protein-losing enteropathy) and functional parameters (including FSV ejection fraction and presence of late gadolinium enhancement, LGE, on CMR and peak metabolic equivalents, pMETs, and peak oxygen consumption, pVO2, at CPET). All statistical tests were two tailed and significance was set at 0.05.

Results

we enrolled 50 patients: 29 had FSLV (58%), FSRV in 21 (42%). Median age at evaluation was 19.5 years [IQR 15–26]; median follow-up was 16 years [4–42]. NYHA class III or IV was present in 6%, while 4 (8%) underwent a re-do Fontan, 2 (4%) entered transplantation waiting list and one of these received a transplant. 2 patients (4%) died at follow-up. Statistical analysis showed that the accessory chamber was larger (&gt;20 cc/m2) in FSLV than in FSRV (p=0.01). In the post-operative period, FSRV was associated with higher incidence of low-cardiac output syndrome (p=0.043). In the long-term, there was no statistically significant difference in major clinical outcomes or NYHA class between the two groups. FSLV was associated with a better cardiac function (median FSV ejection fraction 56% vs 52%; p=0.041), less extent of LGE [p = 0.022], better functional capacity expressed by METs (14.1 vs 12.3; p=0.01) and pVO2 (1.625 ml/min vs 1.233 ml/min; p=0.033). An AVC was detected in all: its size was &lt;5 ml/m2 in 31%, 5–20 ml/m2 in 47%, and &gt;20 ml/m2 in 22%. A larger AVC was associated with higher need for postoperative ECMO support (p=0.007), while size of AVC was not associated to any statistically difference in clinical outcomes, cardiac function and functional capacity.

Conclusions

In Fontan circulation, a FSLV is correlated to better clinical and functional outcomes when compared to FSRV. On the other side, an AVC appears to be not significantly related to any clinical disadvantage. However, the immediate postoperative course may be influenced negatively by the presence of a larger AVC.

Funding Acknowledgement

Type of funding sources: None.

P151 RIGHT VENTRICULAR MECHANICS IN PATIENTS AFFECTED BY PULMONARY VALVE STENOSIS, BEFORE AND AFTER PERCUTANEOUS PULMONARY VALVULOPLASTY

Aim of the Study

To evaluate the mechanical changes of the right ventricle in patients undergoing balloon pulmonary valvuloplasty using transthstandard transthoracic echocardiography (TTE) and speckle–tracking echocardiography (STE) and to investigate the correlation between haemodynamic and echocardiographic parameters before and after treatment.

Materials and Methods

43 pediatric patients (19 males), mean age 3,2±4,9 years with severe pulmonary valve stenosis and indication for percutaneous balloon valvuloplasty were recruited. All patients underwent TTE and STE with analysis of right ventricle global longitudinal strain (RVGLS) one day before and after the procedure. For each patient were collected invasive parameters during balloon valvulopasty.

Results

After the procedure, there was an immediate reduction of both peak–to–peak transpulmonary gradient (Dp post) and ratio between the systolic pressure of right and left ventricle (RV/LV ratio) with a drop of 29,3±14,67mmHg and 0,43±0,03, respectively. Post–procedural echocardiography showed peak and mean transvalvar pressure gradient drop (50±32,23 and 31±17,97, respectively). The degree of pulmonary valve regurgitation was mild in 8% of patients before the procedure, following the intervention it reached 29% with a statistically significant increase (p = 0,007). However, moderate and severe regurgitation remained stable after the procedure. There was a significant improvement of Fractional Area Change (FAC) after the procedure (40,11% vs 44,42%, p = 0,01). TAPSE (p = 0,60) and longitudinal strain (p = 0,31), did not improve significantly after intervention. Finally, pre–procedural invasive RV/LV ratio showed good correlation to echocardiographic transvalvular peak and mean pressure gradient (R = 0,375, p = 0,019 and R = 0,40, p = 0,012, respectively), as well as with FAC (R = 0,31 p = 0,05), TAPSE (R = 0,62 p &lt; 0,001)and RVGLS (R = 0,46 p = 0,01)

Conclusions

Percutaneous balloon pulmonary valvuloplasty represents an efficient and safe procedure. Right ventricular global systolic function improved following afterload reduction, while longitudinal systolic function did not show improvement immediately after intervention. Finally, invasive preprocedural RV/LV ratio demonstrated better correlation with echocardiographic evaluation of stenosis degree and right ventricular function compared to invasive peak–to–peak pressure gradient. Therefore, RV/LV ratio should be preferred for the assessment of pulmonary valve stenosis.

P154 EVOLUTION OF ECHOCARDIOGRAPHIC AND CARDIAC MRI ABNORMALITIES DURING FOLLOW–UP IN PATIENTS WITH PREVIOUS MIS–C DIAGNOSIS

Background

Cardiovascular manifestations in the acute phase of MIS–C are frequent. However, there is lacking evidence regarding late cardiological follow–up of this cohort of patients. The aim of our study was to describe the early and late cardiac abnormalities in patients with MIS–C, assessed by standard echocardiography (TTE), speckle tracking echocardiography (STE), and cardiac MRI (CMR).

Materials and Methods

32 consecutive patients with confirmed MIS–C diagnosis were enrolled in this study. Clinical, laboratory and microbiological data were collected for all patients. At disease onset, all children underwent standard transthoracic echocardiography, STE with analysis of left ventricle global longitudinal strain (GLS) and 23 (75%) of them performed CMR. Patients underwent complete cardiological evaluation, including echocardiography and STE at two months (T1) and six months (T2) after diagnosis. CMR was repeated at six months after diagnosis.

Results

Mean age was 8.25±4years (range 1.3–17.7). Cardiovascular symptoms were present in 45.8% of cases. Thirteen children (40.6%) shared Kawasaki Disease–like symptoms, and 5 (15.6%) needed ICU admission. All patients showed an hyperinflammatory state. Tn–I was elevated in 20 (62.5%) and BNP in 28 (87.5%) patients. Median time to STE evaluation was 7 days and to CMR 18 days since fever onset. Mean LVEF at baseline was 58.8±10% with 10 patients (31%) below 55%. STE showed reduced mean LV GLS (–17.4±4%). Coronary dilation was observed in 9 (28,1%) patients. On CMR, LGE with nonischemic pattern was evident in 8/23 patients (35%). Median time to T1 and T2 evaluation was respectively 48.5 and 207 days. Follow–up data showed statistically significant improvement in left ventricular systolic function compared to acute phase. LVEF improved rapidly at T1 (62.5 ± 7.5 vs. 58.8±10.6%, p value 0.044) with only three patients (10%) below ≤ 55% at T1 and one patient (4%) at T2. LV GLS remained impaired at T1 (–17.2 ± 2.7 vs.–17.4 ± 4, p value 0.71), and significantly improved at T2 (–19±2.6% vs. –17.4±4%, p value 0.009). LV GLS was impaired (&gt;–18%) in 53% of patients at baseline and T1, while only 13% showed LV GLS reduction at T2. CMR, performed 6 months after diagnosis, showed LGE persistence in 33.4% of cases.

Conclusions

Even though, early cardiac involvement significantly improves during follow–up, subclinical myocardial damage seems to be still detectable 6 months follow up in one third of MIS–C patients.

Exercise stress echocardiography in paediatric and adolescent patients

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Exercise stress echocardiography (ESE) is still underused in paediatric patients, and very little data is available for congenital heart diseases (CHDs).

PURPOSE

To describe the current application of ESE in our Paediatric Cardiology Departments.

METHODS

Data from patients who underwent ESE in our Centres, including baseline and under stress symptoms, vital parameters, ECG, and echocardiograms were retrospectively analyzed and compared, as well as clinical management plans formulated based on ESEs results.

RESULTS

Forty-five patients from Centre 1 (median age 16 years), including 87% of patients with CHDs, and 20 patients from Centre 2 (median age 11 years), mainly tested to rule out myocardial ischemia, were included. Among patients from Centre 1, 28 had previously been treated surgically, 6 percutaneously and 11 were under follow-up. Indications for ESE/patients’ native diagnosis are illustrated in the picture.

Centre 1: Exercise was maximal in 17 patients, with 2 of them having symptoms at the peak of exercise. It was stopped beforehand in 28 patients because of dyspnea (3) and muscle fatigue (25). No arrhythmia was detected. ESE was considered as positive in 14 patients; after that, 3 patients underwent percutaneous interventions, 2 underwent cardiac surgery, 3 received indication for cardiac catheterization, 4 for advanced cardiac imaging and 2 for exercise restriction and medical therapy.

Centre 2: Fifteen patients (75%) completed the exercise, and none of them developed symptoms. In the remaining 25%, exercise was stopped because of muscle exhaustion. No arrhythmia was detected, and all the ESEs were negative.

Comparing the cohorts, no significant differences in terms of ejection fraction were noticed at rest and under stress. Patients in cohort 1 were older (p = 0,002), they achieved lower average maximal heart rate (p = 0,0001), performed less lasting exercise (p = 0,05) and ESE was maximal less frequently (p = 0,005). Lastly, they had significant changes in clinical decisions (p = 0,004).

CONCLUSIONS

ESE is a feasible and promising technique in paediatric cardiology, particularly in children with congenital heart diseases, and could influence significantly clinical management plans. Abstract Figure.

OUP accepted manuscript

Aims

Methods and results

Conclusion

Effectiveness of Repair of Aortic Coarctation in Neonates: A Long-Term experience

To evaluate early and long-term results of surgical treatment of aortic coarctation (CoAo) in neonates. This is a retrospective clinical review of neonates with CoAo, who underwent surgery between 1995 and 2019. Data were retrieved from our institutional database, to identify preoperative and postoperative characteristics. Statistical analysis was performed by means of relative risk ratio and Cox and logistic multivariate analysis. 218 consecutive neonates (M/F: 129/89, median age 11 days, IQR 7-17 days) were included; 202 (92.7%) had a left thoracotomy; 178 underwent extended end-to-end anastomosis (EEEA, 81.6%). Hypoplastic aortic arch (HAA) was present in 102 patients (46.8%); complex cardiac anomalies in 85 (39%). Significant postoperative complications occurred in 20 (9.2%). Thirty-day mortality was 2.3% (most in complex types). At a median follow-up of 10.4 years (IQR 5.6-15.0 years; FU completeness 95.9%), there were 8 late deaths (3.7%), all associated to complex CoAo. Among 196 survivors, 177 (93.2%) were in NYHA class I; re-interventions on aortic arch occurred in 9.2% (2.0% were surgical). Freedom from mortality and re-intervention on aorta at 10 years were 94.3% and 96.7%, respectively. Surgical repair of CoAo in newborns without CPB in our series was safe and low-risk, with excellent early and late outcomes.

253 Imaging of congenital AV block caused by maternal autoantibodies: a single-centre experience

Aims

Autoimmune congenital heart block (CHB) is a severe manifestation of neonatal lupus syndrome. There is lack of consensus regarding treatment of pregnant women with anti-SSA/SSB autoantibodies. To evaluate the effectiveness of the combined protocol therapy (oral steroid, plasmapheresis, and IVIG) for the CHB treatment.

Methods and results

All cases of CHB from 2000 to 2020 were retrospectively enrolled. All the patients underwent foetal echocardiography for the evaluation of CHB, ventricular rate and main related foetal complications: cardiomegaly, pericardial and pleural effusion, foetal hydrops, dilated cardiomyopathy, and heart failure. Moreover, postnatal major adverse cardiovascular, such as death and pacemaker implantation, were recorded. For statistical analysis, the population was divided into two cohorts: a protocol group receiving in utero combined therapy and a control group receiving other therapies or not treated. Among 252 pregnancies with anti-SSA/SSB antibodies, 36 developed CHB. At birth, complete CHB treated with protocol therapies showed a significantly higher ventricular rate (P = 0.042), a significant reduction in intrauterine or postnatal mortality (P = 0.018), and a lower rate of pacemaker implantation (P = 0.049).

Conclusions

The combined treatment protocol has proven effective in improving foetal and neonatal short- and long-term survival.

336 Right ventricular mechanics in patients affected by pulmonary valve stenosis, before and after percutaneous pulmonary angioplasty

Aims

Pulmonary valve stenosis accounts for 6–9% of all congenital heart diseases. The main effect of this obstructive lesion is a rise in right ventricular pressure; this overload leads to multiple changes in shape, dimensions, and volume of the ventricle. The diagnosis is based on transthoracic echocardiography and invasive heart catheterization. Usually the stenosis is classified into mild, moderate, and severe based on pressure gradient between right ventricle and pulmonary artery and on the ratio between right ventricle and left ventricle systolic pressure. Percutaneous balloon valvuloplasty is the treatment of choice in severe pulmonary valve stenosis in patients of all ages; alternatively surgical valvotomy is an option in selected cases. The aim of this study is to evaluate the mechanical changes of the right ventricle in patients undergoing balloon pulmonary valvuloplasty using transthoracic and speckle-tracking echocardiography (STE). Furthermore, we sought to investigate the correlation between haemodynamic and echocardiographic parameters to better evaluate the degree of pulmonary valve stenosis before and after treatment.

Methods and results

Forty-three pediatric patients (19 males), mean age 3.2 ± 4.9 years with severe pulmonary valve stenosis and indication for percutaneous balloon valvuloplasty were recruited at the University Hospital of Padua. All patients underwent standard transthoracic echocardiography (TTE), STE with analysis of right ventricle global longitudinal strain (RVGLS) one day before and one day after the procedure. For each patient were collected invasive parameters during the interventional procedure before and after balloon valvuloplasty. After the procedure, there was an immediate statistically significant reduction of both peak-to-peak transpulmonary gradient (Dp post) and ratio between the systolic pressure of right and left ventricle (RV/LV ratio) with a drop of 29.3 ± 14.67 mmHg and 0.43 ± 0.03, respectively. Post-procedural echocardiography showed peak and mean transvalvar pressure gradient drop (50 ± 32.23 and 31 ± 17.97, respectively). The degree of pulmonary valve regurgitation was mild in 8% of patients before the procedure, following the intervention it reached 29% with a statistically significant increase (P = 0.007). However, the incidence of pulmonary valve moderate and severe regurgitation remained stable after the procedure. The analysis of right ventricular function and mechanics showed a significant improvement of Fractional Area Change (FAC) immediately after the procedure (40.11% vs. 44.42%, P = 0,01). On the other hand, right ventricular longitudinal systolic function parameters, TAPSE (P = 0.60) and longitudinal strain (P = 0.31), did not improve significantly after intervention. Finally, pre-procedural invasive RV/LV ratio showed good correlation to echocardiographic transvalvular peak and mean pressure gradient (R = 0.375, P = 0.019 and R = 0.40, P = 0.012, respectively), as well as with FAC (R = 0.31, P = 0.05), TAPSE (R = 0.62, P &lt; 0.001), and RVGLS (R = 0.46, P = 0.01).

Conclusions

Percutaneous balloon pulmonary valvuloplasty represents an efficient and safe procedure to relieve severe pulmonary valve stenosis. Interestingly, the analysis of right ventricular mechanics on echocardiography demonstrated an immediate global systolic function improvement following afterload reduction. Conversely, longitudinal systolic function did not show improvement immediately after intervention, possibly due to the necessity of longer time to recover. Finally, invasive preprocedural RV/LV ratio demonstrated better correlation with echocardiographic evaluation of stenosis degree and right ventricular function compared to invasive peak-to-peak pressure gradient. Therefore, RV/LV ratio should be preferred for the assessment of pulmonary valve stenosis.

122 Exercise stress echocardiography in paediatric and adolescent patients: what is the role?

Aims

To describe the current application of exercise stress echocardiography (ESE) in our Paediatric Cardiology Departments.

Methods and results

Baseline and under stress symptoms, vital parameters, ECG, and echocardiograms from patients who underwent ESE in our centres, were retrospectively analysed and compared, as well as clinical management plans formulated based on ESEs results. Forty-five patients from Centre 1 (median age 16 years), including 87% of patients with congenital heart diseases (CHDs), and 20 patients from Centre 2 (median age 11 years), mainly tested to rule out myocardial ischemia, were included. Among patients from Centre 1, 28 had previously been treated surgically, 6 percutaneously, and 11 were under follow-up. Indications for ESE/patients’ native diagnosis are illustrated in the picture. Centre 1: Exercise was maximal in 17 patients, with 2 of them having symptoms at the peak of exercise. It was stopped beforehand in 28 patients because of dyspnoea (3) and muscle fatigue (25). No arrhythmia was detected. ESE was considered as positive in 14 patients; after that, 3 patients underwent percutaneous interventions, 2 underwent cardiac surgery, 3 received indication for cardiac catheterization, 4 for advanced cardiac imaging, and 2 for exercise restriction and medical therapy. Centre 2: 15 patients (75%) completed the exercise, and none of them developed symptoms. In the remaining 25%, exercise was stopped because of muscle exhaustion. No arrhythmia was detected, and all the ESEs were negative. Comparing the cohorts, no differences in terms of ejection fraction were noticed at rest and under stress. Patients in cohort 1 were older (P = 0.002), they achieved lower average maximal heart rate (P = 0.0001), performed less lasting exercise (P = 0.05), and ESE was maximal less frequently (P = 0.005). Lastly, they had significant changes in clinical decisions (P = 0.004).

Conclusions

In paediatric cardiology, particularly in children with CHDs, ESE is a promising technique and could influence significantly clinical management plans.

610 Fontan associated kidney and liver disease: can we predict organ involvement with echocardiographic assessment of systolic function and atrioventricular valve insufficiency?

Aims

Fontan operation represents the surgical palliative option for congenital heart disease with single ventricle physiology. With the improvement of surgical and percutaneous technique, we are facing a growing population of patients with an unique pathophysiology and potential complications.

Methods and results

Patients that underwent Fontan palliation in our centre between 1993 and 2016 were included in this prospective study. We excluded patients with major congenital renal anomalies, those that underwent cardiac transplantation, and redo-Fontan patients. All the subjects underwent clinical evaluation, laboratory exams with complete renal and hepatic function, transient hepatic elastography, and complete cardiac evaluation. We used Schwartz equation for estimating glomerular filtration rate in patients younger than 18 years, and CDK-EPI equation for adult patients. We enrolled 35 patients, 46% female (N = 16), and 54% male (N = 19). Medium age was 17 years old, median age 15 years old (range: 10–31 years old). Medium time from Fontan completion was 160 months (range: 57–340 months). Regarding to cardiac anatomy, 10 patients had functional single left ventricle (FSLV, 28.5%) and 21 a functional single right ventricle (FSRV, 60%); 4 patients had undetermined single ventricle (11.5%). Total cavo-pulmonary connection (TCPC) with intracardiac lateral tunnel was performed in 7 patients (20%, N = 7), whereas 28 patients had TCPC with external conduit (80%). Data from echocardiographic evaluation showed a medium EF established with Simpson’s method of 60% in patients with FSLV; patients with a FSRV or undetermined single ventricle had a medium FAC of 41.1%, with 15.1% having a reduced FAC &lt; 35%. No FSLV patients had an EF &lt; 50%. When using creatinine-based formula, data about renal function in our population showed a stage 2 chronic kidney disease (eGFR: 60–89 ml/min 1.73 mq) in 11% of total population (N = 4), that became 26% when using cystatin C-based equation (N = 9), with one patient showing a moderate reduced loss of kidney function (eGFR: 40–59 ml/min 1.73 mq). Urinalysis showed 29% (N = 10) of patients having microalbuminuria (microalbumin/creatinine ratio between 30 and 300 mg/g). Statistical analysis demonstrated a negative correlation between systolic function (TAPSE for FSRV) and cystatin C blood levels (Pearson’s R −0.428, P = 0.053), and between systolic function (FAC and Simpson) and microalbuminuria (Pearson’s R −0.414 with P = 0.049 and Pearson’s R −0.754 with P = 0.019, respectively). Transient elastography reported 10 patients (29.4%) with abnormal hepatic stiffness for Fontan patients. That condition appeared to be more frequent in patients with higher grade of AV valve insufficiency (P &lt; 0.05).

Conclusions

Our population showed an higher prevalence of FSRV Fontan patients, with an expected lower systolic function compared with FSLV. 2D evaluation of systolic function showed a linear inverse correlation with renal function, suggesting that Fontan patients need a closer renal monitoring. Hepatic stiffness, which is a warning sign of potential hepatic cirrhosis need to be monitored in all Fontan patients, especially those with a worse AV valve insufficiency.

613 Fontan associated nephropathy: does diastolic function play a role?

Aims

In Fontan patients, the pathophysiology of diastolic function and its relationship with systemic complications are still not well understood.

Methods and results

This is a prospective study including patients who underwent Fontan completion in our centre between 1993 and 2016. We excluded patients with major congenital renal anomalies, those who underwent cardiac transplantation and redo-Fontan patients. All the subjects underwent clinical evaluation, laboratory exams with complete renal and hepatic function, transient hepatic elastography, and complete cardiac evaluation. We used Schwartz equation for estimating glomerular filtration rate in patients younger than 18 years, and CDK-EPI equation for adult patients. We enrolled 35 patients, 46% female (N = 16), and 54% male (N = 19). Medium age was 17 years old (range: 10–31 years old). Medium time from Fontan completion was 160 months (range: 57–340 months). Ten patients had a functional single left ventricle (FSLV, 28.5%) and 21 a functional single right ventricle (FSRV, 60%); four patients had an undetermined single ventricle (11.5%). Data from renal function assessment showed a prevalence of stage 2 chronic kidney disease (eGFR: 60–89 ml/min 1.73 mq). Of those, 11% with creatinine-based equation and 26% (N = 9) when using cystatin C-based equation, with one patients showing a moderate reduced loss of kidney function (eGFR: 40–59 ml/min/1.73 mq). Most of the patients with reduced eGFR measured with cystatin C were FSRV (89%). None had laboratory markers of acute tubular damage, but four patients had signs of chronic tubular dysfunction with elevation of beta 2 microglobulin (13%). Echocardiographic evaluation of diastolic function showed two patients with baseline E/A &lt; 1 (6%, tot N = 33) and 11/33 (33%) pts with abnormal E/E′ (&gt;12). All of them were FSRV patients (100%). Interestingly, statistical correlation between diastolic parameters and renal function showed a significant association between tubular damage parameters, such as alfa1microglobulin and beta2microglobulin, and E/E′ (Pearson’s R 0.4 and 0.48, respectively, P &lt; 0.05), both for FSLV and FSRV patients. Diastolic function appeared to be associated also with glomerular filtration: we found a statistically significant direct correlation between diastolic pulmonary wave deceleration time (dt D wave) and creatinine value (Pearson’s R 0.49, P &lt; 0.05). Supporting the role of diastolic function in Fontan systemic complications is the linear correlation we found with hepatic tests: higher values of aspartate aminotransferase and of gamma-glutamyltransferase were associated with worse diastolic ventricular filling (longer dt D wave and E wave deceleration time, lower TDI early diastolic wave; Pearson’s R 0.45, 0.5, and −0.41, respectively, P &lt; 0.05).

Conclusions

Fontan-related nephropathy is associated with worsening diastolic function, which was more represented in FSRV patients. Diastolic function is also associated with liver disease in Fontan patients. Those data suggest renal and liver function should be closely monitored in patients with impaired diastolic function.

Exercise stress echocardiography in children and teenagers with congenital heart diseases

Background

Exercise Stress Echocardiography (ESE) is currently applied to paediatric patients mainly to detect myocardial ischemia and few data is available for congenital heart diseases (CHDs).

Purpose

The aim of this study is to describe the current application of ESE in our Departments.

Methods

Data from patients who underwent ESE in our two centres were retrospectively analysed, as well as clinical management plans formulated based on ESEs results.

Results

Fifty-five patients (median age 15 years) were included. Among them, 19 had been previously treated surgically, 6 percutaneously and 30 were under follow-up.

Indications for ESE were: hypertension and/or evaluation of aortic arch gradient in patients treated surgically (5) or percutaneously (1) for aortic coarctation (ACo); aortic/subaortic gradient in bicuspid aortic valve (BAV) after balloon valvuloplasty (4), Ross (1), or under follow up (1); right ventricular and pulmonary valve function in Tetralogy of Fallot (3) and after percutaneous treatment of pulmonary atresia (1); atrio-ventricular valves gradient (1 for tricuspid dysplasia and 1 for left cor triatriatum); single ventricle function (1); pulmonary artery gradient (2) and myocardial ischemia (6) after Arterial Switch; rule out myocardial ischemia in coronary anomalies (4), chest pain (9), Kawasaki disease (KD 9), syncope (1) and in patients with ectopic beats under exercise (2); rule out dynamic obstruction in hypertrophic cardiomyopathy (HCM, 3).

The exercise was maximal in 28 patients, with 2 of them having symptoms at the peak of exercise. In the other patients, peak heart rate ranged from 52% to 84% of targeted values. Mean exercise duration and reached Watts were 10 minutes and 112, respectively. Reasons for ending exercise were muscle fatigue in 25 patients and dyspnoea in 2 patients. No arrhythmia was detected.

Clinical management changed in 10 of patients after ESE (20%), all having CHDs. Three patients underwent percutaneous interventions; 1 aortic balloon valvuloplasty, 1 stent dilation and 1 pulmonary valve replacement; 2 underwent surgery (1 aortic valve replacement and 1 subaortic membrane resection), 4 underwent further imaging including cardiac computed tomography (1), cardiac magnetic resonance (2) and cardiac catheterization (1); 1 received indication for restriction from intense physical activities.

Conclusions

ESE has an important clinical role in patients with congenital heart diseases, impacting clinical management.

Funding Acknowledgement

Type of funding sources: None. Indications for ESEChangements in clinical management

Role of Transient Elastography to Stage Fontan-Associated Liver Disease (FALD) in Adults with Single Ventricle Congenital Heart Disease Correction

Fontan-associated liver disease (FALD) is an arising clinical entity that can occur long after a successful Fontan operation for correction of single ventricle (SV) congenital heart disease (CHD). Occurrence of FALD is characterized by liver cirrhosis and other hepatic complications, and determinates an increased morbidity and mortality. Currently, there is no consensus on how to stage FALD. We report here our experience by an observational study in 52 patients with SV-CHD after Fontan operation that were recruited through a period of 36 ± 9.3 months. All cases underwent lab tests and liver and cardiac imaging evaluation, including liver stiffness (LS) measurement by transient elastography (TE) (FibroScan®). According to selective criteria for liver disease, we identified 23/43 (53.5%) cases with advanced FALD that showed: older age (p < 0.05), larger hepatic and cava veins diameter (p < 0.05), worsened NYHA class (p < 0.05), abnormal lymphocytes (p < 0.01), platelet count (p < 0.05), and GGT, prothrombin time (INR), albumin and cystatin C levels (p < 0.05), with respect to cases without advanced FALD. LS values were significantly increased in cases with advanced FALD, at cut-off values higher than 22 kPa (p < 0.001). LS, and its combined score with spleen diameter and platelet count (LSPS) successfully helped to detect 100% of cases with portal hypertension (p < 0.001). In conclusion, LS can be effective to stage FALD and to uncover cases with severe risk of complications, avoiding higher morbidity and mortality related to advanced FALD.

Left ventricle longitudinal strain alterations in asymptomatic or mildly symptomatic pediatric patients with recent SARS-CoV-2 infection

Funding Acknowledgements

Type of funding sources: None.

Background

Evidence suggests that clinical manifestations of children’s COVID-19 may be less severe. However, it has been described the pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) which resembles other inflammatory conditions (i.e. Kawasaki disease). Patients affected by PIMS-TS showed cardiac involvement with myocardial injury, reduced left ventricle systolic function and coronary artery abnormalities. Little is known regarding cardiac involvement in pediatric patients with asymptomatic or mildly symptomatic SARS-CoV-2 infection.

Methods

We analyzed 23 pediatric patients (13males, 56%) with diagnosis of SARS-CoV-2 infection based on PCR analysis of nasopharingeal swab (NPS), and asymptomatic or only mildly symptomatic for COVID-19. Patients underwent standard transthoracic echocardiogram (TTE) within 2-3 month from diagnosis and after negative NPS for SARS-CoV-2. We performed offline analysis with GE EchoPAC software to measure global longitudinal strain (GLS) of the LV using 2D speckle tracking imaging. Therefore, we compared the results with a matched group of 23 controls (13males, 56%).

Results

Cases and controls were similar regarding age (5.9 ± 4.1years vs. 6.4 ± 4.4 years, p = 0.63), body surface area (0.98 ± 0.3m2 vs. 0.8 ± 0.4m2, p = 0.17), LV FS (37.9 ± 5.9% vs. 36.4 ± 8.3%, p = 0.74) and LV biplane EF (63.9 ± 5.2% vs. 66.4 ± 5.3%, p = 0.11). GLS analysis showed significant strain reduction of the LV mid-wall segments and of the basal anterior, posterior and septal inferior segments among cases compared to controls. Furthermore, in the case group there were 7 subjects (30%) with a strain below 16.5% in at least 3 segments.

Conclusion

SARS-CoV-2 infection may affect LV deformation in asymptomatic or only mildly symptomatic children, showing a peculiar pattern with lower longitudinal strain in all mid-wall segments of LV compared to control subjects. The clinical significance of this findings is unclear and follow-up is needed to verify the reversibility of this alterations.

Pulmonary Artery Banding for Ventricular Rehabilitation in Infants With Dilated Cardiomyopathy: Early Results in a Single-Center Experience

Background: Pulmonary artery banding (PAB) is reported as an innovative strategy for children with end-stage heart failure (ESHF) to bridge to transplantation or recovery. We report our early experience with PAB to evaluate outcomes, indications, and limitations. Materials and Methods: This is a single-center prospective clinical study, including infants and children admitted for ESHF owing to dilated cardiomyopathy (DCM) with preserved right ventricular function after failure of maximal conventional therapy. All patients underwent perioperative anticongestive medical therapy with ACE inhibitor, beta blocker, and spironolactone. Post-operatively, all patients underwent echocardiographic follow-up to assess myocardial recovery. Results: We selected five patients (four males) who underwent PAB at a median age of 8.6 months (range 3.9-42.2 months), with preoperative ejection fraction (EF) <30%. Sternal closure was delayed in all. One patient did not improve after PAB and underwent Berlin Heart implantation after 33 days, followed by heart transplant after 13 months. Four patients were discharged home on full anticongestive therapy. However, 2 months after discharge, one patient experienced severe acute heart failure secondary to pneumonia, which required mechanical circulatory support, and the patient underwent a successful heart transplant after 21 days. The remaining three patients are doing well at home, 22.4, 16.9, and 15.4 months after PAB. They all underwent elective percutaneous de-banding, 18.5, 4.8, and 10.7 months after PAB. EF increased from 17.7 ± 8.5% to 63.3 ± 7.6% (p = 0.03), and they have all been delisted. Conclusion: Use of PAB may be an effective alternative to mechanical support in selected infants for bridging to transplant or recovery. Better results seem to occur in patients aged <12 months. Further experience and research are required to identify responders and non-responders to this approach.

Carotid Artery Approach as an Alternative to Femoral access for Balloon Dilation of Aortic Valve Stenosis in Neonates and Infants

Purpose

to evaluate the efficacy of a right common carotid artery cutdown as alternative access in neonates and small infants requiring a balloon dilation of aortic valve stenosis. In infants, the femoral approach is limited by difficulties in advancing the catheter across the valve and by the risk of femoral artery injuries.

Methods

from January 1997 to July 2000, 16 infants at our department underwent balloon dilation through a carotid artery cutdown. Infant weight ranged from 2670 to 6450 g; mean weight 3967 g, and age ranged from 1 to 157 days, mean age 42,8 days. Fifteen of 16 infants had aortic valve stenosis; the remaining infant presented with a aortic coartation relapse.

Results

In 15 infants an adequate dilation of the valve was obtained with no complications. In only one infant an arterial intimal disconnection was caused by inadequate choice of surgical instruments. At the end of the procedure, the carotid arteries were reconstructed with interrupted 7-0 prolene stitches. There were no neurological sequaelae observed. All infants were followed-up and examined by echocolordoppler ultrasound: all carotid arteries were open with no significant stenosis.

Conclusion

Our experience confirms that the carotid access proposed in 1973 by Azzolina et al is a valid and safe alternative to the usual percutaneous femoral access. In particular it could be useful in neonates and infants were the size of femoral vessels could facilitate important and dangerous complications.

JAG1 Loss-Of-Function Variations as a Novel Predisposing Event in the Pathogenesis of Congenital Thyroid Defects

CONTEXT

The pathogenesis of congenital hypothyroidism (CH) is still largely unexplained. We previously reported that perturbations of the Notch pathway and knockdown of the ligand jagged1 cause a hypothyroid phenotype in the zebrafish. Heterozygous JAG1 variants are known to account for Alagille syndrome type 1 (ALGS1), a rare multisystemic developmental disorder characterized by variable expressivity and penetrance.

OBJECTIVE

Verify the involvement of JAG1 variants in the pathogenesis of congenital thyroid defects and the frequency of unexplained hypothyroidism in a series of ALGS1 patients.

DESIGN, SETTINGS, AND PATIENTS

A total of 21 young ALGS1 and 100 CH unrelated patients were recruited in academic and public hospitals. The JAG1 variants were studied in vitro and in the zebrafish.

RESULTS

We report a previously unknown nonautoimmune hypothyroidism in 6/21 ALGS1 patients, 2 of them with thyroid hypoplasia. We found 2 JAG1 variants in the heterozygous state in 4/100 CH cases (3 with thyroid dysgenesis, 2 with cardiac malformations). Five out 7 JAG1 variants are new. Different bioassays demonstrate that the identified variants exhibit a variable loss of function. In zebrafish, the knock-down of jag1a/b expression causes a primary thyroid defect, and rescue experiments of the hypothyroid phenotype with wild-type or variant JAG1 transcripts support a role for JAG1 variations in the pathogenesis of the hypothyroid phenotype seen in CH and ALGS1 patients.

CONCLUSIONS

clinical and experimental data indicate that ALGS1 patients have an increased risk of nonautoimmune hypothyroidism, and that variations in JAG1 gene can contribute to the pathogenesis of variable congenital thyroid defects, including CH.

Pacemaker remote monitoring in the pediatric population: is it a real solution?

BACKGROUND

Clinical utility of remote monitoring of implantable cardiac devices has been previously demonstrated in several trials in the adult population. The aim of this study was to assess the clinical utility of remote monitoring in a pediatric population undergoing pacemakers implantation.

METHODS

The study population included 73 consecutive pediatric patients who received an implantable pacemaker. The remote device check was programmed for every 3 months and all patients had a yearly out-patient visit. Data on device-related events, hospitalization, and other clinical information were collected during remote checks and out-patient visits.

RESULTS

During a mean follow-up of 18 ± 10 months, 470 remote transmissions were collected and analyzed. Two deaths were reported. Eight transmissions (1.7%) triggered an urgent out-patient visit. Twenty percent of transmissions reported evidence of significant clinical or technical events. All young patients and their families were very satisfied when using remote monitoring to replace out-patient visits.

CONCLUSIONS

The ease in use, together with satisfaction and acceptance of remote monitoring in pediatric patients, brought very good results. The remote management of our pediatric population was safe and remote monitoring adequately replaced the periodic out-patient device checks without compromising patient safety.

Usefulness of fetal three-dimensional ultrasonography for detecting of congenital heart defects and associated syndromes

Congenital heart defects (CHDs) occur in 1% of live-born infants and frequently are associated with extracardiac malformations. This study aimed to assess the feasibility and accuracy of three-dimensional ultrasonography (3DUS) in fetuses with CHD and to investigate whether 3DUS can add information about the heart and general fetal morphology that shows other congenital malformations or suggests syndromes. For 30 fetuses affected by CHD, 3DUS was performed using a Sonos 7500 ultrasound machine with a cardiac 3D transducer. In 44% of the exams, 3DUS was completely diagnostic for the CHD, providing additional information in 28% of the exams. Furthermore, 3DUS showed 82% of associated malformations, providing the complete diagnosis in 57% of the cases and helping with recognition of syndromes in others. The diagnostic accuracy of 3DUS was superior, with a higher number of acquisitions per exam. Performance was better in fetuses younger than 24 weeks for general morphologic details and in fetuses older than 24 weeks for the heart morphology.

Heart transplantation in pediatric age

Heart transplantation, formerly the final option for terminally ill children, has now become the treatment of choice for a number of serious acquired or congenital cardiac conditions, which cannot be treated conservatively. Nevertheless, several problems remain unsolved. First of all the shortage of donors, mainly in the first months and years of life, which has become more and more significant with time, regardless of the country, religious belief or culture of the people. Secondly, the long-term impact of immunosuppression in a developing organism, and its possible inter-relation with the primary disorder, which leads to intractable heart failure. Whether a heart transplant is a cure or an ongoing disease for both the child and the family is another matter of concern. These and other topics are covered in this article.

Critical Aortic Stenosis in Early Infancy: Surgical Treatment for Residual Lesions After Balloon Dilation

BACKGROUND

The optimal management for critical aortic stenosis in early infancy continues to challenge cardiologists and cardiac surgeons. We present a review of our experience with the surgical treatment of residual aortic valve disease after percutaneous balloon dilation for critical aortic stenosis in early infancy.

METHODS

Since 1989, 11 of the 38 patients who survived aortic balloon dilation (28.9%) have undergone surgical treatment for residual aortic valve dysfunction. Median time from aortic balloon dilation to surgical intervention was 7 months (range 1 to 56 months). Residual aortic stenosis was the predominant problem in 8 patients and aortic regurgitation was predominant in 2 patients.

RESULTS

Aortic valvuloplasty was possible in 5 children; pulmonary autograft replacement of the aortic valve was performed in 6 children. Two children underwent a Ross-Konno procedure because of annulus hypoplasia and severe left ventricular outflow tract obstruction. Two early deaths occurred after a Ross-Konno procedure, both with findings of severe left ventricular fibroelastosis at the pathologic examination. Median follow-up time was 5 years (range 1 month to 11.9 years). No late deaths occurred. One patient with moderate-severe aortic valve regurgitation after aortic valvuloplasty underwent a successful Ross operation. All 9 patients are asymptomatic and are in good clinical condition.

CONCLUSIONS

We are convinced that the best aortic valve in the pediatric age group is the native one, provided it can function acceptably. However, in cases where conservative surgical treatment fails to yield a functional aortic valve, replacement of the valve is indicated, and the best aortic valve substitute in infants is the pulmonary autograft because of its potential for growth.

Carotid artery approach as an alternative to femoral access for balloon dilation of aortic valve stenosis in neonates and infants

PURPOSE

to evaluate the efficacy of a right common carotid artery cutdown as alternative access in neonates and small infants requiring a balloon dilation of aortic valve stenosis. In infants, the femoral approach is limited by difficulties in advancing the catheter across the valve and by the risk of femoral artery injuries.

METHODS

from January 1997 to July 2000, 16 infants at our department underwent balloon dilation through a carotid artery cutdown. Infant weight ranged from 2670 to 6450 g; mean weight 3967 g, and age ranged from 1 to 157 days, mean age 42,8 days. Fifteen of 16 infants had aortic valve stenosis; the remaining infant presented with a aortic coartation relapse.

RESULTS

In 15 infants an adequate dilation of the valve was obtained with no complications. In only one infant an arterial intimal disconnection was caused by inadequate choice of surgical instruments. At the end of the procedure, the carotid arteries were reconstructed with interrupted 7-0 prolene stitches. There were no neurological sequaelae observed. All infants were followed-up and examined by echocolordoppler ultrasound: all carotid arteries were open with no significant stenosis.

CONCLUSION

Our experience confirms that the carotid access proposed in 1973 by Azzolina et al is a valid and safe alternative to the usual percutaneous femoral access. In particular it could be useful in neonates and infants were the size of femoral vessels could facilitate important and dangerous complications.

Systolic and diastolic performance late after the Fontan procedure for a single ventricle and comparison of those undergoing operation at <12 months of age and at >12 months of age

To evaluate whether surgical history can influence systolic and diastolic properties of a functional single left ventricle after Fontan operation, we echocardiographically investigated 31 patients (mean age 93.7 months; range 21 to 276); 21 patients were >12 months of age (group A) and 10 were <12 months of age (group B) at the time of the Fontan and/or cavopulmonary procedure. In group A we found persistent abnormalities of left ventricular mass index (95.9 vs 64.1 g/m(2), p <0.05) at long-term follow-up, whereas group B had normal left ventricular mass (61.9 vs 64.1 g/m2, p = NS). In contrast, a diastolic pattern characterized by augmented late diastolic filling was present in both patient groups regardless of age at operation and length of follow-up (E/A in group A 1.3 +/- 0.4, E/A in group B 1.6 +/- 1.5, E/A in controls 1.7 +/- 0.6; A vs B, p = NS; A vs controls, p <0.05). We concluded that patients with a single left ventricle who undergo an unloading procedure performed within the first year of life have complete normalization of left ventricular mass, although a diastolic filling pattern suggestive of augmented compliance persists, regardless of the age at operation.

Repair of congenital mitral valve dysplasia in infants and children: is it always possible?

OBJECTIVES

Surgical management of congenital malformation of the mitral valve (MV) in the pediatric age group remains a therapeutic challenge for the wide spectrum of the morphological abnormalities and the high incidence of associated cardiac anomalies. We reviewed our experience so as to assess whether MV conservative surgery is always advisable and its results are superior to MV replacement.

METHODS

Thirty-four consecutive children (20 male and 14 female) with a mean age of 5.9 years (range 45 days-18 years) treated surgically for congenital MV disease between January 1987 and June 1999. Four patients (11.7%) were under 12 months of age, while 21 patients (62%) were younger than 5 years. Twenty-two patients presented with MV incompetence (or prevalent incompetence), while 12 presented with stenosis (or prevalent stenosis). Associated cardiac lesions were present in 22 patients (62.8%).

RESULTS

Mitral valve reconstruction was possible in all. There were no operative deaths. Three patients required reoperation for MV restenosis (a re-repair in one and MV replacement with mechanical prosthesis in two) 4 months, 27 months and 5.6 years after repair with no operative deaths. There was only one late death for prosthetic valve thrombosis. Follow-up data reveal that the 33 surviving patients are asymptomatic and well 4 months-12 years (mean 72 months) after surgery. At 12 years, actuarial survival and freedom from reoperation are 96.8 and 85.9%, respectively. Echocardiography performed in all of them shows no or mild incompetence or stenosis in 26 (78%), while residual moderate MV incompetence persists in six.

CONCLUSIONS

Our experience indicates that MV reconstructive procedures in infants and children with congenital MV dysplasia may be effective and reliable with low mortality and low incidence of reoperation rate. Mitral valve repair should always be attempted, especially in infants, despite the frequent severity of MV dysplasia, to avoid the drawbacks of the currently available prostheses.