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Papatheodorou E, Pantou M, Gourzi P, Bakalakos A, Tsatsopoulou A, Vlagkouli V, Rammos S, Papagiannis J, Efraimidis M, Degiannis D, Vardas P, Anastasakis A. Genetic testing in consecutive cases of acute and clinically suspected myocarditis with noise in the family. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Myocarditis is increasingly associated with dilated cardiomyopathy (DCM) and arrhythmogenic cardiomyopathy (ACM).
Purpose
The aim of our study was to define if a genetic predisposition exists in cases of myocarditis with suspicious findings of inherited cardiovascular disease (noise) in the family.
Methods
Consecutive patients referred to our unit from 2010 to 2021, with a presentation of acute or clinically suspected myocarditis, as defined by current criteria, went through family screening of the first and second-degree relatives. Patients fulfilling typical criteria for definite ARVC upon presentation were excluded. Patients with suspicious familial findings (familial noise) including a. family history of sudden cardiac death, b. family history of myocarditis or cardiomyopathy or c. findings suggestive of cardiac disease in the relatives (ECG abnormalities, complex or frequent ventricular arrhythmias, conduction disease, troponemia, structural abnormalities suggestive of cardiomyopathy) went through genetic analysis for 90 genes associated with cardiomyopathy.
Results
Fifty-five patients with myocarditis and familial noise were included (Table 1). In 49 (89%) patients ≥2 diagnostic criteria for clinically suspected myocarditis were fulfilled. In 50% of the patients, the noise in the family was revealed upon familial screening as there was no relevant family history. Myocardial inflammation was confirmed in 16 (29%) patients with histological findings on endomyocardial biopsy or ≥2 Lake Louise Criteria on cardiac magnetic resonance. Pathogenic or likely pathogenic variants were identified in 78% of the cases (figure 1). Desmoplakin (24%) followed by lamin A/C (13%) and titin (9%) were the most common genes identified. In cases with confirmed myocardial inflammation the genetic yield increased to 87%.
Conclusions
A significant proportion of myocarditis patients with “familial noise” carry a pathogenic genetic variant in a cardiomyopathy related gene. These findings potentially affect the clinical management and need for family and genetic screening in patients with clinically suspected myocarditis.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Greek Network for Precision Medicine in Cardiology and the Prevention of Sudden Cardiac Death in the Young, icardiacnet
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Affiliation(s)
| | - M Pantou
- Onassis Cardiac Surgery Center , Athens , Greece
| | - P Gourzi
- Onassis Cardiac Surgery Center , Athens , Greece
| | - A Bakalakos
- Barts Heart Centre , London , United Kingdom
| | - A Tsatsopoulou
- Yannis Protonotarios Medical Center of Naxos , Naxos , Greece
| | - V Vlagkouli
- Onassis Cardiac Surgery Center , Athens , Greece
| | - S Rammos
- Onassis Cardiac Surgery Center , Athens , Greece
| | | | - M Efraimidis
- Onassis Cardiac Surgery Center , Athens , Greece
| | - D Degiannis
- Onassis Cardiac Surgery Center , Athens , Greece
| | - P Vardas
- Hygeia Hospital , Athens , Greece
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Baumeier C, Aleshcheva G, Harms D, Gross U, Hamm C, Assmus B, Westenfeld R, Kelm M, Rammos S, Wenzel P, Münzel T, Elsässer A, Gailani M, Perings C, Bourakkadi A, Flesch M, Kempf T, Bauersachs J, Escher F, Schultheiss HP. Intramyocardial Inflammation after COVID-19 Vaccination: An Endomyocardial Biopsy-Proven Case Series. Int J Mol Sci 2022; 23:ijms23136940. [PMID: 35805941 PMCID: PMC9266869 DOI: 10.3390/ijms23136940] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/20/2022] [Accepted: 06/21/2022] [Indexed: 12/11/2022] Open
Abstract
Myocarditis in response to COVID-19 vaccination has been reported since early 2021. In particular, young male individuals have been identified to exhibit an increased risk of myocardial inflammation following the administration of mRNA-based vaccines. Even though the first epidemiological analyses and numerous case reports investigated potential relationships, endomyocardial biopsy (EMB)-proven cases are limited. Here, we present a comprehensive histopathological analysis of EMBs from 15 patients with reduced ejection fraction (LVEF = 30 (14–39)%) and the clinical suspicion of myocarditis following vaccination with Comirnaty® (Pfizer-BioNTech) (n = 11), Vaxzevria® (AstraZenica) (n = 2) and Janssen® (Johnson & Johnson) (n = 2). Immunohistochemical EMB analyses reveal myocardial inflammation in 14 of 15 patients, with the histopathological diagnosis of active myocarditis according the Dallas criteria (n = 2), severe giant cell myocarditis (n = 2) and inflammatory cardiomyopathy (n = 10). Importantly, infectious causes have been excluded in all patients. The SARS-CoV-2 spike protein has been detected sparsely on cardiomyocytes of nine patients, and differential analysis of inflammatory markers such as CD4+ and CD8+ T cells suggests that the inflammatory response triggered by the vaccine may be of autoimmunological origin. Although a definitive causal relationship between COVID-19 vaccination and the occurrence of myocardial inflammation cannot be demonstrated in this study, data suggest a temporal connection. The expression of SARS-CoV-2 spike protein within the heart and the dominance of CD4+ lymphocytic infiltrates indicate an autoimmunological response to the vaccination.
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Affiliation(s)
- Christian Baumeier
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (G.A.); (D.H.); (U.G.); (F.E.); (H.-P.S.)
- Correspondence: ; Tel.: +49-30-8441-5543
| | - Ganna Aleshcheva
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (G.A.); (D.H.); (U.G.); (F.E.); (H.-P.S.)
| | - Dominik Harms
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (G.A.); (D.H.); (U.G.); (F.E.); (H.-P.S.)
| | - Ulrich Gross
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (G.A.); (D.H.); (U.G.); (F.E.); (H.-P.S.)
| | - Christian Hamm
- Kerckhoff Heart Center, Department of Cardiology, 61231 Bad Nauheim, Germany;
- Department of Cardiology and Angiology, Universitätsklinikum Gießen und Marburg, 35391 Gießen, Germany;
| | - Birgit Assmus
- Department of Cardiology and Angiology, Universitätsklinikum Gießen und Marburg, 35391 Gießen, Germany;
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany; (R.W.); (M.K.)
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany; (R.W.); (M.K.)
| | - Spyros Rammos
- Onassis Cardiac Surgery Center, 176 74 Athens, Greece;
| | - Philip Wenzel
- Department of Cardiology, University Medical Center Mainz, 55131 Mainz, Germany; (P.W.); (T.M.)
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, 55131 Mainz, Germany; (P.W.); (T.M.)
| | - Albrecht Elsässer
- Department of Cardiology, Klinikum Oldenburg, 26133 Oldenburg, Germany;
| | | | - Christian Perings
- Department of Cardiology, St. Marien-Hospital, 44534 Lünen, Germany;
| | - Alae Bourakkadi
- Department of Internal Medicine, Cardiology, Geriatrics and Palliative Medicine, Gemeinschaftsklinikum Mittelrhein gGmbH, 56727 Mayen, Germany;
| | - Markus Flesch
- Department of Cardiology, Marienkrankenhaus gGmbH, 59494 Soest, Germany;
| | - Tibor Kempf
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany; (T.K.); (J.B.)
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany; (T.K.); (J.B.)
| | - Felicitas Escher
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (G.A.); (D.H.); (U.G.); (F.E.); (H.-P.S.)
- Department of Cardiology, Campus Virchow-Klinikum, Charité University Medicine Berlin, 13353 Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Heinz-Peter Schultheiss
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (G.A.); (D.H.); (U.G.); (F.E.); (H.-P.S.)
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3
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Gourzi P, Pantou MP, Vagenakis G, Tsoutsinos A, Vatsellas G, Makrythanasis P, Rammos S, Degiannis D. Genetic predisposition in pediatric acute myocarditis: a pilot study. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Myocarditis is an inflammatory disease of the heart muscle with a wide range of clinical presentations, from asymptomatic to cardiogenic shock and death. Although acute myocarditis is rare in pediatric population, it is caused by common viral infections, like parvovirus B19 or enteroviruses. Limited scientific evidence supports the existence of a genetic background that could underlay the susceptibility to virus-induced myocarditis.
Purpose
The aim of the present study was to identify mutations in genes associated with cardiomyopathies, that could possibly underly acute myocarditis in pediatric patients with biopsy-proven parvovirus B19 infection, verified by real time PCR.
Methods
Nine pediatric patients presented in our center with acute myocarditis were genotyped with next generation sequencing using Clinical Exome Solution kit (Sophia Genetics) covering 4493 disease-related genes. Variant pathogenicity was accessed according to guidelines by American College of Medical Genetics (2015).
Results
Genetic analysis revealed that three of the nine patients were found positive for pathogenic/likely pathogenic mutations in TTR, ABCC6 and SLC22A5 genes. The patient that carried the SLC22A5 variant initially received telbivudine and her ejection fraction was improved from 20% to 45%. Genetic test results suggested that the patient may suffer from mild L-carnitine deficiency. Oral supplementation with high dose of L-carnitine during one month period improved dramatically her EF to normal (65%). The patient that carried the ABCC6 mutation, also carried a variant of unknown significance in MYH7 gene. Four patients carried variants of unknown significance. The variants of unknown significance detected in MYBPC3, SCN5A, and MYH7 genes are of particular interest since they accumulate evidence of pathogenicity. Two patients did not harbor any mutations.
Conclusion
A significant proportion of rare variants in genes associated with cardiomyopathies has been identified in a small cohort of pediatric patients with parvovirus-induced acute myocarditis. The findings of our study, although limited, support the existence of a genetic background that could function as a predisposing factor influencing the clinical course of the disease.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Onassis Foundation
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Affiliation(s)
- P Gourzi
- Onassis Cardiac Surgery Center, Molecular Immunopathology & Histocompatibility Unit, Athens, Greece
| | - M P Pantou
- Onassis Cardiac Surgery Center, Molecular Immunopathology & Histocompatibility Unit, Athens, Greece
| | - G Vagenakis
- Onassis Cardiac Surgery Center, Department of Paediatric Cardiology and Adult with Congenital Heart Disease, Athens, Greece
| | - A Tsoutsinos
- Onassis Cardiac Surgery Center, Department of Paediatric Cardiology and Adult with Congenital Heart Disease, Athens, Greece
| | - G Vatsellas
- Biomedical Research Institute Academy of Athens, Athens, Greece
| | - P Makrythanasis
- National & Kapodistrian University of Athens Medical School, Laboratory of Medical Genetics, Athens, Greece
| | - S Rammos
- Onassis Cardiac Surgery Center, Department of Paediatric Cardiology and Adult with Congenital Heart Disease, Athens, Greece
| | - D Degiannis
- Onassis Cardiac Surgery Center, Molecular Immunopathology & Histocompatibility Unit, Athens, Greece
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Karatza AA, Kiaffas M, Rammos S. Complete heart block complicating the acute phase of respiratory syncytial virus bronchiolitis. Pediatr Pulmonol 2017; 52:E61-E63. [PMID: 28486756 DOI: 10.1002/ppul.23714] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 03/31/2017] [Indexed: 02/05/2023]
Abstract
Respiratory syncytial virus is the most common pathogen causing lower respiratory tract infection in infants. In recent years, the importance of extrapulmonary complications and longterm sequelae including those involving the cardiovascular system has become apparent. We report on a 10 month old infant with respiratory syncytial virus bronchiolitis, the acute phase of which was complicated by irreversible complete heart block, which was managed conservatively.
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Affiliation(s)
- Ageliki A Karatza
- Department of Paediatrics, University of Patras Medical School, Patras, Greece
| | - Maria Kiaffas
- Department of Paediatric Cardiology and Adult with Congenital Heart Disease, Onassis Cardiac Surgery Center, Athens, Greece
| | - Spyros Rammos
- Department of Paediatric Cardiology and Adult with Congenital Heart Disease, Onassis Cardiac Surgery Center, Athens, Greece
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5
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Giannakoulas G, Vasiliadis K, Frogoudaki A, Ntellos C, Tzifa A, Brili S, Manginas A, Ntiloudi D, Mousiama T, Kolios M, Pitsis A, Giamouzis G, Karvounis H, Tsioufis K, Rammos S. P744Risk stratification in pulmonary arterial hypertension associated with congenital heart disease. Results from CHALLENGE registry. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx501.p744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - K. Vasiliadis
- General Hospital G. Papanikolaou, Cardiology Department, Thessaloniki, Greece
| | - A. Frogoudaki
- Attikon University Hospital, Cardiology Department, Athens, Greece
| | - C. Ntellos
- Tzaneio General Hospital of Piraeus, Cardiology Department, Athens, Greece
| | - A. Tzifa
- Mitera General Hospital, Department of Congenital Heart Disease, Athens, Greece
| | - S. Brili
- Hippokration General Hospital, Cardiology Department, Athens, Greece
| | - A. Manginas
- Mediterraneo Hospital, Cardiology Department, Athens, Greece
| | - D. Ntiloudi
- AHEPA General Hospital, Thessaloniki, Greece
| | - T. Mousiama
- Tzaneio General Hospital of Piraeus, Cardiology Department, Athens, Greece
| | - M. Kolios
- University Hospital of Ioannina, Cardiology Department, Ioannina, Greece
| | - A. Pitsis
- Agios Loukas Hospital, Department of Cardiothoracic Surgery, Thessaloniki, Greece
| | - G. Giamouzis
- University General Hospital of Larissa, Cardiology Department, Larissa, Greece
| | | | - K. Tsioufis
- Hippokration General Hospital, Cardiology Department, Athens, Greece
| | - S. Rammos
- Onassis Cardiac Surgery Center, Department of Paediatric and Congenital Cardiac Surgery, Athens, Greece
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6
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Chatzis AC, Tsoutsinos AJ, Kanakis MA, Contrafouris CA, Rammos S, Mitropoulos FA. Situs Inversus Totalis: Single-Stage Anatomic Repair of Complex Congenital Heart Disease. World J Pediatr Congenit Heart Surg 2016; 9:254-256. [PMID: 27881809 DOI: 10.1177/2150135116670631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transposition of the great arteries occurs rarely in patients with mirror image dextrocardia and situs inversus, while the combination with severe coarctation of the descending aorta (CoA) makes the anatomy even more unusual. Therefore, it is not surprising that a case with such unusual and complicated anatomy presents unique problems when a primary definitive correction is attempted. We report a patient with situs inversus totalis and complex congenital heart disease including transposition of the great arteries and severe CoA who underwent successful complete, single-stage, anatomic correction.
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Affiliation(s)
- Andrew C Chatzis
- 1 Department of Paediatric and Congenital Cardiac Surgery, Onassis Cardiac Surgery Centre, Athens, Greece
| | | | - Meletios A Kanakis
- 1 Department of Paediatric and Congenital Cardiac Surgery, Onassis Cardiac Surgery Centre, Athens, Greece
| | | | - Spyros Rammos
- 2 Department of Paediatric Cardiology, Onassis Cardiac Surgery Centre, Athens, Greece
| | - Fotios A Mitropoulos
- 1 Department of Paediatric and Congenital Cardiac Surgery, Onassis Cardiac Surgery Centre, Athens, Greece
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7
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Cannizzaro D, Brinjikji W, Rammos S, Murad MH, Lanzino G. Changing Clinical and Therapeutic Trends in Tentorial Dural Arteriovenous Fistulas: A Systematic Review. AJNR Am J Neuroradiol 2015; 36:1905-11. [PMID: 26316563 DOI: 10.3174/ajnr.a4394] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/05/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Tentorial dural arteriovenous fistulas are characterized by a high hemorrhagic risk. We evaluated trends in outcomes and management of tentorial dural arteriovenous fistulas and performed a meta-analysis evaluating clinical and angiographic outcomes by treatment technique. MATERIALS AND METHODS We performed a comprehensive literature search for studies on surgical and endovascular treatment of tentorial dural arteriovenous fistulas. We compared the proportion of patients undergoing endovascular, surgical, and combined endovascular/surgical management; the proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas; and proportion of patients with good neurologic outcome across 3 time periods: 1980-1995, 1996-2005, and 2006-2014. We performed a random-effects meta-analysis, evaluating the rates of occlusion, long-term good neurologic outcome, perioperative morbidity, and resolution of symptoms for the 3 treatment modalities. RESULTS Twenty-nine studies with 274 patients were included. The proportion of patients treated with surgical treatment alone decreased from 38.7% to 20.4% between 1980-1995 and 2006-2014. The proportion of patients treated with endovascular therapy alone increased from 16.1% to 48.0%. The proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas decreased from 64.4% to 43.6%. The rate of good neurologic outcome increased from 80.7% to 92.9%. Complete occlusion rates were highest for patients receiving multimodality treatment (84.0%; 95% CI, 72.0%-91.0%) and lowest for endovascular treatment (71.0%; 95% CI, 56.0%-83.0%; P < .01). Long-term good neurologic outcome was highest in the endovascular group (89.0%; 95% CI, 80.0%-95.0%) and lowest for the surgical group (73.0%; 95% CI, 51.0%-87.0%; P = .03). CONCLUSIONS Patients with tentorial dural arteriovenous fistulas are increasingly presenting with unruptured lesions, being treated endovascularly, and experiencing higher rates of good neurologic outcomes. Endovascular treatment was associated with superior neurologic outcomes but lower occlusion rates.
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Affiliation(s)
- D Cannizzaro
- From the Departments of Neurosurgery (D.C., G.L.)
| | | | - S Rammos
- Department of Neurosurgery (S.R.), Arkansas Neuroscience Institute, Little Rock, Arkansas
| | - M H Murad
- Center for Science of Healthcare Delivery (M.H.M.), Mayo Clinic, Rochester, Minnesota
| | - G Lanzino
- From the Departments of Neurosurgery (D.C., G.L.)
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8
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Kourkoveli P, Rammos S, Parissis J, Maillis A, Kremastinos D, Paraskevaidis I. Depressive Symptoms in Patients with Congenital Heart Disease: Incidence and Prognostic Value of Self-Rating Depression Scales. CONGENIT HEART DIS 2014; 10:240-7. [DOI: 10.1111/chd.12200] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2014] [Indexed: 12/14/2022]
Affiliation(s)
- Panagiota Kourkoveli
- Department of Pediatric Cardiology and Adult Congenital Heart Disease; Onassis Cardiac Surgery Center; Athens Greece
| | - Spyros Rammos
- Department of Pediatric Cardiology and Adult Congenital Heart Disease; Onassis Cardiac Surgery Center; Athens Greece
| | - John Parissis
- Department of Cardiology; Attikon Hospital; National and Kapodistrian University of Athens; Athens Greece
| | - Antonis Maillis
- Department of Pediatric Cardiology and Adult Congenital Heart Disease; Onassis Cardiac Surgery Center; Athens Greece
- Department of Psychiatry; Aeginitio Hospital; National and Kapodistrian University of Athens; Athens Greece
| | - Dimitrios Kremastinos
- Department of Cardiology; Attikon Hospital; National and Kapodistrian University of Athens; Athens Greece
| | - Ioannis Paraskevaidis
- Department of Cardiology; Attikon Hospital; National and Kapodistrian University of Athens; Athens Greece
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9
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Fischer G, Apostolopoulou SC, Rammos S, Schneider MB, Bjørnstad PG, Kramer HH. The Amplatzer Membranous VSD Occluder and the vulnerability of the atrioventricular conduction system. Cardiol Young 2007; 17:499-504. [PMID: 17634162 DOI: 10.1017/s1047951107000984] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Transcatheter closure of ventricular septal defects with the Amplatzer Membranous VSD Occluder has yielded promising initial results, but disturbances of conduction, including complete heart block, have been reported. We report our experience with the Amplatzer occluder in 35 patients with a median age 4.5 years, the defects being sized angiographically at 4.4 plus or minus 1.1 millimetres, with a range from 3 to 8 millimetres, and the size of the occluder varying from 4 to 12 millimetres. Over a median follow-up of 2.5 years, the rate of complete closure was 87% and 91%, at 1 and 2 years respectively, while 2 patients required surgical closure of the defect subsequent to the insertion of the device. Persistent regurgitation across the tricuspid valve related to the occluder was observed in 3 patients, and in 6 patients across the aortic valve. Abnormalities of conduction related to the procedure were noted in 7 patients, one-fifth of the cohort. The disturbances were transient in 1 patient, but permanent in 6, in one of the latter progressing after 6 months from left bundle branch block to intermittent Mobitz II second-degree atrioventricular block in association with expansion of the occluder. We conclude that transcatheter closure of perimembranous ventricular septal defects with the Amplatzer occluder is effective with limited complications, but the incidence of immediate and progressive disturbances of conduction related to the proximity of conduction tissues to the rims of the occluder stress the importance of larger and longer studies to assess the safety of this procedure.
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Affiliation(s)
- Gunther Fischer
- Klinik für Kinderkardiologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Germany.
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10
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Fischer G, Apostolopoulou SC, Rammos S, Kiaffas M, Kramer HH. Transcatheter closure of coronary arterial fistulas using the new Amplatzer vascular plug. Cardiol Young 2007; 17:283-7. [PMID: 17445336 DOI: 10.1017/s1047951107000510] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2006] [Indexed: 11/06/2022]
Abstract
We report our initial experience in using the Amplatzer vascular plug for closure of coronary arterial fistulas. The self-expanding, cylindrical, device is made from Nitinol wire mesh, and is available from 4 to 16 millimetres in diameter. We have now used the device to close fistulas in 3 patients, aged from 3 to 14 years, who presented with ratios of pulmonary-to-systemic flow from 1.5 to 3. In 2 patients, fistulas arising from the proximal right and left coronary arteries, with maximal diameters of 9 and 10 millimetres, respectively, had their narrowest diameter, of 6 millimetres, proximal to the entrance into the right atrium via a saccular aneurysm. The third fistula, with a maximal diameter of 16 millimetres, and with its origin from the circumflex coronary artery, entered the right atrium with nearly unrestricted flow, its narrowest diameter being 8 millimetres. For interventional closure, we chose plugs twice the diameter of the narrowest segment of the fistula, thus using 2 devices of 12 millimetres and one of 16 millimetres diameter. An arteriovenous loop was established through the fistula by snaring an exchange guide wire. Using a 7 or 8 French guide catheter inserted through the femoral vein, all plugs were placed at the narrowest segment of the fistula, leading to immediate complete closure of 2 fistulas. The third patient, with a fistula of the circumflex coronary artery, who received the largest plug initially had residual flow, but the fistula was found to be completely occluded at 12 months follow-up examination. We have demonstrated, therefore, safe and effective usage of the new vascular plug for transcatheter closure of moderate- to large-sized coronary arterial fistulas. The plug offers an alternative to cardiac surgery, or occlusion using coils.
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Affiliation(s)
- Gunther Fischer
- Klinik für Kinderkardiologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Germany.
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11
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Apostolopoulou SC, Manginas A, Cokkinos DV, Rammos S. Long-term oral bosentan treatment in patients with pulmonary arterial hypertension related to congenital heart disease: a 2-year study. Heart 2006; 93:350-4. [PMID: 16980516 PMCID: PMC1861451 DOI: 10.1136/hrt.2006.100388] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the long-term clinical and exercise effect of chronic oral administration of the non-selective endothelin receptor antagonist bosentan in patients with pulmonary arterial hypertension (PAH) related to congenital heart disease (CHD). DESIGN Extension of a preceding prospective non-randomised open clinical study on bosentan treatment in PAH related to CHD. SETTING A tertiary referral centre for cardiology. PATIENTS 19 of the original 21 patients of mean (standard deviation (SD)) age 22 (3) years (13 with Eisenmenger syndrome) in World Health Organization (WHO) class II-IV and having a mean (SD) oxygen saturation of 87 (2) %. INTERVENTION Patients received bosentan treatment for 2.4 (0.1) years and underwent clinical and exercise evaluation at baseline, 16 weeks and 2 years of treatment, with haemodynamic assessment at baseline and 16 weeks. RESULTS All patients remained stable with sustained subjective clinical and WHO class improvement (p<0.01) at 16 weeks and 2 years of treatment without significant side effects or changes in oxygen saturation. After the initial 16-week improvement (p<0.05) in peak oxygen consumption and exercise duration at treadmill test, and walking distance and Borg dyspnoea index at 6-min walk test, all exercise parameters appeared to return to their baseline values at 2 years of follow-up. CONCLUSIONS Long-term bosentan treatment in patients with PAH related to CHD is safe and induces clinical stability and improvement, but the objective exercise values appear to slowly return to baseline. Larger studies on long-term endothelin receptor antagonism including quality of life assessment are needed to evaluate the therapeutic role of bosentan in this population.
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Affiliation(s)
- S C Apostolopoulou
- Department of Paediatric Cardiology, Onassis Cardiac Surgery Centre, Athens, Greece.
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Apostolopoulou SC, Manginas A, Cokkinos DV, Rammos S. Effect of the oral endothelin antagonist bosentan on the clinical, exercise, and haemodynamic status of patients with pulmonary arterial hypertension related to congenital heart disease. Heart 2005; 91:1447-52. [PMID: 15761050 PMCID: PMC1769173 DOI: 10.1136/hrt.2004.051961] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the clinical, exercise, and haemodynamic effects of chronic oral administration of the non-selective endothelin receptor antagonist bosentan on patients with pulmonary arterial hypertension (PAH) related to congenital heart disease (CHD). DESIGN Prospective non-randomised open clinical study. SETTING Cardiology tertiary referral centre. PATIENTS 21 patients with a mean (SEM) age of 22 (3) years with chronic PAH related to CHD (15 with Eisenmenger's syndrome). Patients were in World Health Organization (WHO) class II to IV with oxygen saturation 87 (2)%. INTERVENTION Patients underwent clinical, exercise, and haemodynamic evaluations at baseline and after 16 weeks of treatment. RESULTS Bosentan improved (p < 0.01) WHO class, peak oxygen consumption from 16.8 (1.4) to 18.3 (1.4) ml/kg/min, exercise duration from 9.0 (0.8) to 10.7 (0.6) minutes during the treadmill test, walking distance from 416 (23) to 459 (22) m, and Borg dyspnoea index from 2.8 (0.2) to 2.0 (0.1) during the six minute walk test. Bosentan treatment improved (p < 0.05) mean pulmonary artery pressure from 87 (4) to 81 (4) mm Hg, pulmonary blood flow index from 3.2 (0.4) to 3.7 (0.5) l/min/m2, pulmonary to systemic blood flow ratio from 1.2 (0.2) to 1.4 (0.2), and pulmonary vascular resistance index from 2232 (283) to 1768 (248) dyn.s.cm(-5). Two patients died, presumably of arrhythmic causes, who were in WHO class IV at baseline and who had improved during treatment. CONCLUSIONS Bosentan induces short and mid term clinical, exercise, and haemodynamic improvements in patients with PAH related to CHD. Larger studies with long term endothelin receptor antagonism are needed to assess the safety and possible treatment role of bosentan in this population.
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Affiliation(s)
- S C Apostolopoulou
- Department of Paediatric Cardiology, Onassis Cardiac Surgery Centre, Athens, GR 176 74, Greece.
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13
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Apostolopoulou SC, Rammos S, Kyriakides ZS, Webb DJ, Johnston NR, Cokkinos DV, Kremastinos DT. Acute endothelin A receptor antagonism improves pulmonary and systemic haemodynamics in patients with pulmonary arterial hypertension that is primary or autoimmune and related to congenital heart disease. Heart 2003; 89:1221-6. [PMID: 12975426 PMCID: PMC1767875 DOI: 10.1136/heart.89.10.1221] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the acute haemodynamic effect of BQ-123, a selective endothelin A receptor antagonist, in severe chronic pulmonary arterial hypertension (PAH) of primary or autoimmune origin or related to congenital heart disease. DESIGN Prospective open clinical study. SETTING Cardiology tertiary referral centre. PATIENTS 26 patients with chronic PAH were studied, with mean (SEM) age 29 (3) years (range 4-71 years), mean pulmonary artery pressure 68 (4) mm Hg, and pulmonary vascular resistance index 1694 (170) dyne x s x cm(-5). Patients were divided in three groups according to PAH aetiology: primary or autoimmune PAH (n = 12), and PAH associated with congenital heart defects with (n = 6) or without (n = 8) complete mixing. INTERVENTION BQ-123 200 nmol/min was infused for 60 minutes in the right atrium with sequential haemodynamic measurements at 30 minute intervals. RESULTS BQ-123 improved mean pulmonary artery pressure from 68 (4) to 64 (4) mm Hg (p < 0.05), pulmonary vascular resistance index from 1694 (170) to 1378 (145) dyne x s x cm(-5) (p < 0.001), pulmonary cardiac index from 3.0 (0.2) to 3.4 (0.3) l/min/m2 (p < 0.001), and effective cardiac index from 2.5 (0.2) to 2.7 (0.2) l/min/m2 (p < 0.01). Haemodynamic response was similar in all groups except for systemic cardiac index where a different (p = 0.0001, F = 5.53) response was observed; systemic cardiac index increased from 2.7 (0.2) to 2.9 (0.2) l/min/m2 (p < 0.001) when patients with complete mixing were excluded, in whom systemic cardiac index tended to decrease from 3.4 (1.0) to 3.0 (0.6) l/min/m2 (p = 0.06). CONCLUSIONS Acute endothelin A receptor antagonism induces substantial haemodynamic improvement in severe chronic PAH of primary or autoimmune origin or related to congenital heart disease.
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Affiliation(s)
- S C Apostolopoulou
- Department of Paediatric Cardiology, Onassis Cardiac Surgery Centre, Athens, Greece.
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14
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Chatzis AC, Giannopoulos NM, Bobos D, Kirvassilis GB, Rammos S, Sarris GE. New xenograft valved conduit (Contegra) for right ventricular outflow tract reconstruction. Heart Surg Forum 2003; 6:396-8. [PMID: 14721819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
BACKGROUND The well-known flaws of existing valved conduits for reconstruction of the right ventricular outflow tract (RVOT) continue to stimulate research for the elusive "perfect" conduit. In this study, we describe our experience with a glutaraldehyde-treated bovine jugular vein valved conduit (Contegra). METHODS 55 years underwent implantation of a Contegra conduit. Diagnoses/procedures included repair of truncus arteriosus (2 patients), pulmonary atresia (3 patients), severe pulmonary insufficiency after prior repair of tetralogy of Fallot (9 patients), and replacement of degenerated valved conduit (1 patient). RESULTS No operative deaths occurred. One patient required an early conduit replacement for unexplained valve thrombosis. The early postoperative mean transconduit pressure gradient was 7.7+/- 4.9 mm Hg. At a mean follow-up time of 18.5 +/- 6.9 months, all patients were asymptomatic with no discernible calcification in the valve or conduit or significant valve incompetence, while the mean transvalvular gradient remained low (11.1 +/- 4.5 mm Hg). CONCLUSION The Contegra valved conduit is well suited for RVOT reconstruction, avoids the use of additional foreign material, and remains well functioning during early followup. Nonetheless, the long-term durability remains to be ascertained.
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Affiliation(s)
- Andrew C Chatzis
- Department of Paediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Centre, Athens, Greece.
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15
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Giannopoulos NM, Chatzis AK, Karros P, Zavaropoulos P, Papagiannis J, Rammos S, Kirvassilis GV, Sarris GE. Early results after transatrial/transpulmonary repair of tetralogy of Fallot. Eur J Cardiothorac Surg 2002; 22:582-6. [PMID: 12297176 DOI: 10.1016/s1010-7940(02)00403-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVES Right ventricular (RV) dysfunction is a significant cause of morbidity and mortality after surgical correction of tetralogy of Fallot (TOF). Transatrial/transpulmonary repair avoids a ventriculotomy (in contrast to the transventricular approach) emphasizing maximal preservation of RV structure and function. We have adopted this technique as less traumatic for the right ventricle. This study evaluates the early surgical results of our approach. METHODS Between September 1997 and July 2001, 110 consecutive patients with TOF were referred to our unit for surgical therapy. Of these, 14 were unsuitable for repair and underwent aortopulmonary shunting+/-pulmonary artery patching. In the remaining 96 patients (median age 1.4 years), complete transatrial/transpulmonary repair was performed. Previously placed shunts (ten patients) were taken down and any secondary stenoses or branch pulmonary artery distortion repaired. In all cases, subpulmonary resection and ventricular septal defect (VSD) closure were accomplished transatrially. Whenever pulmonary valvotomy and valve ring widening were necessary, it was achieved through a pulmonary arteriotomy. In 84 patients the main pulmonary artery was augmented with an autologous pericardial patch, and in 23 the patch was extended to pulmonary artery branch(es). A limited (<1cm ) or extended (>1cm, but <or=length of RV infundibulum) transannular incision was necessary in 59 and 18 patients, respectively, in order to achieve an adequate residual RV outflow tract diameter. A monocusp autologous pericardial valve was placed in 13 patients. RESULTS There was no death in this series. No patient required permanent pacemaker. In one case, early reoperation for residual RV outflow tract obstruction was needed. Median ICU and hospital stay were 3.5 and 10 days, respectively. At median follow up of 26 (mean 25+/-12) months, all patients are asymptomatic, with no significant residual lesion. CONCLUSIONS Transatrial/transpulmonary repair of TOF is associated with remarkably low morbidity and mortality in our early experience.
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Affiliation(s)
- N M Giannopoulos
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, 356 Sygrou Avenue, Athens, Greece
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16
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Korbmacher B, Krogmann ON, Rammos S, Godehardt E, Volk T, Schulte HD, Gams E. Repair of critical aortic coarctation in neonatal age. J Cardiovasc Surg (Torino) 2002; 43:1-6. [PMID: 11803319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND The data of 111 (male: 64; female: 47) in the period of 1967 until 12/93 consecutive operated neonatals (<1 month) were studied retrospectively (mean weight 3270 g, mean age at operation 14 days). METHODS Preductal anatomy was present in 96 patients. The coarctation was isolated in 30 patients (group I), 34 patients had additional large ventricular septal defects (group II) and 47 had complex heart disease (group III). The preoperative heart catheterization revealed a gradient of <20 mmHg in 35%, >20 mmHg in 51.4% and >50 mmHg in 12.9%. The indication for repair was conservatively untreatable heart insufficiency. In the vast majority (n=97) of patients resection and end-to-end anastomosis were performed, in 31 cases using an absorbable suture, in 18 of these using a continuous suture line. In 4 patients a subclavian flap angioplasty (SFA) was done, in 4 a patch enlargement, 4 times a repair was described as not possible and in 2 patients there was no gradient after division of the ductus. RESULTS Early lethality was 3.3% (n=1) in group I, 24.2% (n=8) died in group II and 39.1% (n=18) in group III; after introducing Prostaglandin E1 0% in group I, 15% in II and 25% in III. Relevant recoarctation (Gradient >20 mmHg) developed in 9 (among them 4 with hypoplastic arch, 2 after SFA) of the 77 long-term survivors; 6 of these were reoperated on, 5 without residual gradient, 1 with a gradient of 25 mmHg without clinical symptoms (after 4 years). In the last 3 patients a balloon dilation was carried out without residual gradient. Mean follow-up time was 6 (0-24) years. No patient needs antihypertensive treatment. The cumulative survival rate is 96.7% (+6.6%) for group I, 77.4% (+15.0%) for II and 51.9% (+16.6%) for III. CONCLUSIONS Resection and end-to-end anastomosis using a continuous absorbable suture is the method of choice at theoretical considerations and in our experiences. The number of recoarctations in neonatal age is relatively high; reinterventions (operation respectively dilation) can be done safely and successfully.
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Affiliation(s)
- B Korbmacher
- Clinic of Thoracic and Cardiovascular Surgery, Medical Center, Düsseldorf, Germany
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17
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Papagiannis J, Apostolopoulou S, Sarris GE, Rammos S. Diagnosis and management of pulmonary arteriovenous malformations. Images Paediatr Cardiol 2002; 4:33-49. [PMID: 22368610 PMCID: PMC3232512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pulmonary arteriovenous malformation is a rare anomaly that presents in several different ways. It can present as an isolated finding, or more often in the context of hereditary haemorrhagic telangiectasia. It can also complicate palliative surgery such as the Glenn operation for complex congenital heart disease with single ventricle physiology. Its management includes transcatheter embolization, which is the preferred mode of therapy, surgery (including resection of the affected lobe, segment, or the fistula itself), or rarely, medical therapy. Complications of the disease itself and of various modes of treatment are relatively common, and patients require close surveillance for possible recurrence, or development of new fistulas. In cases related to the Glenn operation, redirection of hepatic venous flow or heart transplantation may cure the problem.
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Affiliation(s)
- J Papagiannis
- Division of Pediatric Cardiology and Pediatric Cardiac Surgery, Onassis Cardiac Surgery Center,Contact information: Dr. John Papagiannis, Division of Pediatric Cardiology, Onassis Cardiac Surgery Center, 356 Sygrou Ave, 176 74 Kallithea-Athens, GREECE Telephone #: +3010-9493865 Fax #: +3010-9403853
| | - S Apostolopoulou
- Division of Pediatric Cardiology and Pediatric Cardiac Surgery, Onassis Cardiac Surgery Center
| | - GE Sarris
- Division of Pediatric Cardiology and Pediatric Cardiac Surgery, Onassis Cardiac Surgery Center
| | - S Rammos
- Division of Pediatric Cardiology and Pediatric Cardiac Surgery, Onassis Cardiac Surgery Center
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18
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Apostolopoulou SC, Kelekis NL, Papagiannis J, Hausdorf G, Rammos S. Transcatheter occlusion of a large pulmonary arteriovenous malformation with use of a Cardioseal device. J Vasc Interv Radiol 2001; 12:767-9. [PMID: 11389232 DOI: 10.1016/s1051-0443(07)61452-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Large pulmonary arteriovenous malformations (PAVMs) carry a significant risk of neurologic complications and present technical difficulties in transcatheter treatment with use of coils or detachable balloons. A 26-year-old man with a giant PAVM, who had undergone unsuccessful attempted closure with use of a Gianturco-Grifka occlusion device in the past, underwent successful transcatheter embolization with two Cardioseal double umbrella devices designed for occlusion of intracardiac communications. The procedure was technically easy, had no complications, and provided sustained improvement in arterial saturation and exercise tolerance during follow-up. Transcatheter double umbrella device occlusion of large arteriovenous malformations is feasible and should be considered, especially for very large fistulas.
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Affiliation(s)
- S C Apostolopoulou
- Department of Pediatric Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
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19
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Korbmacher B, Büttgen S, Schulte HD, Hoffmann M, Krogmann ON, Rammos S, Gams E. Long-term results after repair of total anomalous pulmonary venous connection. Thorac Cardiovasc Surg 2001; 49:101-6. [PMID: 11339445 DOI: 10.1055/s-2001-11706] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Operative strategies and early results concerning repair of Total Anomalous Pulmonary Venous Connection (TAPVC) are relatively well known. Less well defined data are available to evaluate the long-term outcome. We would therefore like to contribute our long-term data in this presentation. PATIENTS AND METHODS Between 1958 and 1992 52 consecutive patients aged two days to 42 years (15 neonates, 16 infants, 9 children and 12 adults) with TAPVC were operated on. The data were collected retrospectively from the records. In 24 patients, a current follow-up study was performed, including clinical evaluation, echocardiography, and a twenty-four-hour ambulatory ECG. RESULTS Early mortality was 34.6% (n = 18). The postoperative follow-up period ranged from 4 months to 28 years (mean 10.7 years). There were 4 late deaths, yielding an overall long-term mortality of 7.7% (4/52). Causes of death were severe hypoplasia of central pulmonary veins in 1, ventricular fibrillation (2) and non-cardiac in one case. 80% of the operative survivors were available for assessment. Preoperatively, 11 of these patients were in NYHA functional class II, six in class III and seven in class IV. After treatment, 22 patients were in class I and two in class II. Ventricular function was evaluated by echocardiography and invasive catheterization. Only two of 24 patients (8%) showed an abnormal IVS-motion and enlargement of the right ventricle. Cardiac catheterization revealed a mean PA pressure of 26 mmHg, the peak systolic pressure in the RV was 34 mmHg. All 24 long-term survivors underwent assessment of cardiac rhythm by 24 h electrocardiogramm (ECG) monitoring. Significant arrhythmias were recorded in 11 of 24 cases (46%), including sinus node dysfunction in 3 patients. Multiform ventricular ectopic beats were evaluated in 9 cases. According to the Lown classification, 7 patients were class I while 2 cases were considered to be class IV. CONCLUSIONS A normal hemodynamic state can be achieved in most cases. Significant arrhythmias may exist in asymptomatic patients late after surgical correction of TAPVC, and therefore, long-term follow-up of these patients, including 24 h ECG monitoring, is recommended, even if they are asymptomatic.
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Affiliation(s)
- B Korbmacher
- Clinic of Thoracic and Cardiovascular Surgery, Heinrich-Heine University Medical Center Düsseldorf, Germany
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20
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Abstract
We present a case of transcatheter closure of an atrial baffle leak with significant systemic to pulmonary atrium shunt in a patient late after Mustard operation and pulmonary valvotomy for transposition of the great arteries. This procedure alleviated the need for reoperation in a high-risk symptomatic patient. Cathet. Cardiovasc. Intervent. 51:305-307, 2000.
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Affiliation(s)
- S C Apostolopoulou
- Department of Pediatric Cardiology, Onassis Cardiac Surgery Center, Athens, Greece.
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21
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Abstract
Double-outlet left ventricle is a rare congenital cardiac malformation that has been traditionally difficult to diagnose accurately. We report a unique case of situs inversus totalis, L-loop, double-inlet left ventricle and double-outlet left ventricle with pulmonary stenosis, diagnosed mainly by transesophageal echocardiography and magnetic resonance imaging.
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Affiliation(s)
- J Papagiannis
- Division of Pediatric Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
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22
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Abstract
UNLABELLED We report two children with acquired third degree AV-block caused by acute myocarditis. The diagnosis was proven by endomyocardial biopsy. Severe lymphocytic myocardial infiltration was shown using immunohistological methods. One of the children was treated with prednisone During therapy conduction disturbance nearly disappeared and infiltration was markedly reduced in a subsequent biopsy. In the other patient the parents refused immunosuppressive treatment and a permanent pacemaker was necessary for persistent bradycardia. CONCLUSION Immunohistological staining of an endomyocardial biopsy can be used to establish the diagnosis of myocarditis in patients with atypical clinical manifestation, such as complete AV-block, and can support the decision for therapy. In one patient improvement was documented by the disappearance of inflammatory activity in a repeated biopsy.
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Affiliation(s)
- A Heusch
- Department of Paediatric Cardiology, Heinrich-Heine-University, Düsseldorf, Germany
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23
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Korbmacher B, Buhl R, Schmitt HH, Rammos S, Kemnitz J, Radermacher P. Longterm efficiency of high dose inotropic support in an infant after repair of Fallot's tetralogy. J Cardiovasc Surg (Torino) 1996; 37:409-11. [PMID: 8698788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A 23 month old boy with highly symptomatic tetralogy of Fallot (TOF) underwent repair. Inspite of cold Bretschneider cardioplegic solution twice the heart was beating soon after application of the cardioplegic solution each time. Soon after transfer to the intensive care unit the patient developed low cardiac output (LCO). The following days high doses of inotropic support ware necessary to maintain sufficient arterial pressure. The dosages of dobutamine (up to 49 micrograms/kg/min); norepinephrine (up to 5.28 micrograms/kg/min, and epinephrine (up to 16 micrograms/kg/min), respectively, were twice and three times as high as common maximum recommendations. After having recovered from acute renal failure requiring hemodialysis from the 5th to the 37th postoperative day the child was discharged 9 weeks after the intervention. The very unusual and interesting course of this boy is described and the form and grade of the inotropic support is discussed.
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Affiliation(s)
- B Korbmacher
- Clinic of Thoracic and Cardiovascular Surgery, Heinrich Heine-University of Düsseldorf, Germany
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24
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Klement D, Rammos S, v Kries R, Kirschke W, Kniemeyer HW, Greinacher A. Heparin as a cause of thrombus progression. Heparin-associated thrombocytopenia is an important differential diagnosis in paediatric patients even with normal platelet counts. Eur J Pediatr 1996; 155:11-4. [PMID: 8750802 DOI: 10.1007/bf02115618] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
UNLABELLED A 15-year-old boy developed deep vein thrombosis of the right leg 9 days after appendectomy. In spite of three courses of thrombolysis with streptokinase and effective heparinization the thrombosis progressed with additional occlusion of the left iliac vein. Although platelet counts were constantly normal, heparin-associated thrombocytopenia was suspected as the cause of the new venous occlusions. This diagnosis was confirmed by detecting heparin-associated antibodies with the heparin-induced platelet activation test. Therapy was instituted replacing heparin by the low molecular weight heparinoid Orgaran. Bilateral recanalization occurred within 6 days. CONCLUSION Heparin-associated thrombocytopenia must be considered if thrombosis occurs or progresses despite effective heparinization even in the absence of thrombocytopenia.
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Affiliation(s)
- D Klement
- Abteilung für Pädiatrie, Heinrich-Heine-Universität Düsseldorf, Germany
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25
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Abstract
UNLABELLED This study reports our experience with low-dose prostaglandin E1 (PGE1) treatment of 91 newborns with ductus dependent congenital heart disease (CHD). PGE1 efficacy, side-effects as well as the cardiovascular and respiratory profile of the patients were analysed. PGE1 doses > 0.02 microgram/kg per minute were used for only 5.3% of the total 23,656 h of treatment. The mean systolic blood pressures did not differ from the normal mean for patients with cyanotic CHD, while the diastolic values were lowered. Respiratory support was required only during 13.7% of the total treatment time. Apnoeas occurred in 21 (38%) of the 55 spontaneously breathing infants, who all had a cyanotic CHD. The incidence of apnoeas was lower during treatment with doses < 0.01 microgram/kg per minute. CONCLUSION PGE1 can be successfully administered in lower doses than previously recommended. Especially high initial doses can be avoided and low maintenance doses allow long-term treatment without serious complications.
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Affiliation(s)
- H H Kramer
- Department of Paediatric Cardiology, Children's Hospital, Heinrich-Heine-University, Düsseldorf, Germany
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26
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Korbmacher B, Rammos S, Schmitt HH, Heusch A, Schulte HD, Bircks W. Left aortic arch and right descending aorta--interruption or severe coarctation of the aortic arch in the newborn. Cardiovasc Surg 1995; 3:73-7. [PMID: 7780716 DOI: 10.1016/0967-2109(95)92909-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Three consecutive neonates (aged 7, 14 and 30 days, body-weight 2980 g, 3000 g and 3400 g respectively) with interruption of the aorta (n = 2) and severe coarctation (n = 1) in the presence of left aortic arch and right descending aorta are reported. Associated lesions were an aortopulmonary window in the first case and an unrestrictive ventricular septal defect in the two others. Intractable heart failure and the complexity of the malformation led to the decision of a staged operation. A prosthetic graft was interposed between the ascending and descending aorta via a right thoracotomy in order to bridge the atretic or hypoplastic segment without using extracorporeal circulation. There was no intraoperative complication. One patient developed a thrombocytopenia within the frame of a sepsis syndrome and died on day 5 after operation, death being caused by a massive bleeding into the left thoracic cavity, although the operation was carried out via a right thoracotomy. Angiography 1 year after operation revealed a good flow through the grafts and no stenosis at the site of the anastomoses. The two surviving infants are clinically well without any medication. The reported operative technique provides an alternative palliative possibility to manage critically ill neonates without any obstacle to later definitive repair.
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Affiliation(s)
- B Korbmacher
- Department of Thoracic and Cardiovascular Surgery, Heinrich Heine University of Düsseldorf, Germany
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27
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Abstract
Low dose (3 ppm) inhaled nitric oxide caused selective pulmonary vasodilation with improved systemic arterial pressure, cardiac index and arterial oxygenation in an infant with primary pulmonary hypertension. Methaemoglobin levels did not exceed 0.6%, and nitrogen dioxide concentrations remained within 0.05 ppm.
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Affiliation(s)
- P Radermacher
- Universitätsklinik für Anästhesiologie, Klinikum der Universität, Ulm, Germany
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28
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Abstract
Seventy-two children were treated with propafenone between 1980 and 1990. The mean age was 34 months (range 0-192). Arrhythmias included atrioventricular re-entry tachycardia in 32 patients (44%), atrial flutter in 16 (22%), atrial or junctional ectopic tachycardia in 10 (14%), atrial re-entry tachycardias in three (4%) and ventricular arrhythmias in 11 patients (16%). The efficacy of oral treatment was good in patients with atrio-ventricular re-entry tachycardia (80%), atrial flutter (71%) and atrial ectopic tachycardia (83%); it was poor in ventricular arrhythmias (40%). The mean oral dose was 13.5 mg.kg-1. day-1. Dosage and serum levels of propafenone did not differ whether the patients were treated successfully or not. No correlation between dosage and serum level was observed. Intravenous propafenone administration was only partially successful in suppressing supraventricular tachycardias (6 of 11 patients). The presence of a congenital heart defect and the time of onset of the arrhythmias had a significant influence on the efficacy of propafenone. Better results were observed in patients with normal hearts and in whom onset of arrhythmia was pre-natal (success 80%) as well as in patients with arrhythmias seen early after surgery for congenital heart defects (success 87%). Success (65%) was also observed in patients without congenital heart defects and postnatal onset of supraventricular arrhythmias. Patients with ventricular or supraventricular arrhythmias late after corrective surgery showed the poorest response (31%).
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MESH Headings
- Administration, Oral
- Adolescent
- Arrhythmias, Cardiac/blood
- Arrhythmias, Cardiac/drug therapy
- Arrhythmias, Cardiac/physiopathology
- Atrial Flutter/blood
- Atrial Flutter/drug therapy
- Atrial Flutter/physiopathology
- Cardiac Complexes, Premature/blood
- Cardiac Complexes, Premature/drug therapy
- Cardiac Complexes, Premature/physiopathology
- Child
- Child, Preschool
- Electrocardiography/drug effects
- Female
- Heart Conduction System/drug effects
- Heart Conduction System/physiopathology
- Heart Defects, Congenital/blood
- Heart Defects, Congenital/drug therapy
- Heart Defects, Congenital/physiopathology
- Humans
- Infant
- Infant, Newborn
- Infusions, Intravenous
- Male
- Propafenone/adverse effects
- Propafenone/blood
- Propafenone/therapeutic use
- Retrospective Studies
- Tachycardia, Atrioventricular Nodal Reentry/blood
- Tachycardia, Atrioventricular Nodal Reentry/drug therapy
- Tachycardia, Atrioventricular Nodal Reentry/physiopathology
- Tachycardia, Ectopic Atrial/blood
- Tachycardia, Ectopic Atrial/drug therapy
- Tachycardia, Ectopic Atrial/physiopathology
- Tachycardia, Ectopic Junctional/blood
- Tachycardia, Ectopic Junctional/drug therapy
- Tachycardia, Ectopic Junctional/physiopathology
- Tachycardia, Supraventricular/blood
- Tachycardia, Supraventricular/drug therapy
- Tachycardia, Supraventricular/physiopathology
- Tachycardia, Ventricular/blood
- Tachycardia, Ventricular/drug therapy
- Tachycardia, Ventricular/physiopathology
- Treatment Outcome
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Affiliation(s)
- A Heusch
- Department of Pediatric Cardiology, Heinrich-Heine-University, Düsseldorf, Germany
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Korbmacher B, Rammos S. Two-stage sternal closure after repair of congenital heart disease in neonates. Cardiovasc Surg 1993; 1:660-3. [PMID: 8076117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Closure of the longitudinal sternal incision can lead to unacceptable impairment of the haemodynamic state after prolonged operation for complex congenital heart disease associated with decreased cardiac function which is caused by cardiac dilatation. Between 1981 and 1991, a two-stage sternal closure was used in 21 neonates with dilatation of the heart and low cardiac output after correction of congenital heart disease. The mean age at operation was 14 (range 4-30) days. In 15 patients (group 1), primary closure of the sternum was considered impossible in the operating room; in the remaining six (group 2), the sternum was reopened on the day of operation or on the first or second day after repair. Three of these newborn infants had a total anomalous pulmonary venous connection and 18 a simple transposition of the great arteries. In all patients, temporary closure of the thorax with a dura mater patch was performed. The patch was usually removed on day 4 after operation in the intensive care unit and followed by uncomplicated routine chest closure. There were no problems with mediastinitis, wound infection, osteomyelitis or instability of the sternum. Subsequent deformity of the thorax was not observed. Some 11 of 15 children (73%) of group 1 and four of six (66%) of group 2 survived. Leaving the sternum open resulted in a significant improvement in the haemodynamics in all patients. The technique of two-stage closure of the sternum is very effective after lengthy corrective operation in children with congenital malformations of the heart who require long periods of perfusion or ischaemia.
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Affiliation(s)
- B Korbmacher
- Department of Thoracic and Cardiovascular Surgery, Heinrich-Heine University of Düsseldorf, Germany
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Rosenbaum T, Rammos S, Kniemeyer HW, Göbel U. Extended deep vein and inferior vena cava thrombosis in a 15-year-old boy: successful lysis with recombinant tissue-type plasminogen activator 2 weeks after onset of symptoms. Eur J Pediatr 1993; 152:978-80. [PMID: 8131815 DOI: 10.1007/bf01957219] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We present the case of a 15-year-old boy with thrombosis of the inferior vena cava, the femoral, inguinal, and renal veins of unknown origin. Although the thrombosis was 2 weeks old, thrombolytic therapy with recombinant tissue-type plasminogen activator (maximum dosage: 0.4 mg/kg/h) was started as this appeared to be the only change to re-establish normal kidney function. After 1 week, treatment was discontinued because of generalized bleeding. At this time, the infrarenal inferior vena cava was again patent with complete lysis of all other clots. Phlebography 3 months after lysis documented an abnormal renal vein, a tubular, subhepatical stenosis of the inferior vena cava and a large collateral vessel between the inferior vena cava and the azygos vein.
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Affiliation(s)
- T Rosenbaum
- Department of Paediatrics, Heinrich Heine Universität, Düsseldorf, Germany
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31
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Heusch A, Rammos S, Korbmacher B, Schulte HD, Bourgeois M. [Pulmonary artery sling. A rare disease picture with variable clinical symptoms]. Monatsschr Kinderheilkd 1993; 141:651-4. [PMID: 8377769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
In two patients with obstruction of the upper respiratory airways, echocardiography, subsequent angio-cardiography and bronchoscopy disclosed the presence of a pulmonary artery sling. The clinical course of the disease, the diagnostic approach and the procedures for surgical repair are described. Embryological as well as differential diagnostic aspects are discussed with regard to the literature.
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Affiliation(s)
- A Heusch
- Zentrum für Kinderheilkunde, Heinrich-Heine-Universität Düsseldorf
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Krogmann ON, Kramer HH, Rammos S, Heusch A, Bourgeois M. Non-invasive evaluation of left ventricular systolic function late after coarctation repair: influence of early vs late surgery. Eur Heart J 1993; 14:764-9. [PMID: 8325302 DOI: 10.1093/eurheartj/14.6.764] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The study was designed to assess non-invasively the long-term effect of coarctation repair on systemic blood pressure, left ventricular (LV) muscle mass (LMM) and LV systolic function. Blood pressure and pressure gradients across the coarctation site were measured at rest and during exercise. LV systolic function and LMM were assessed by echocardiography. Twenty-eight patients late after successful coarctation repair were divided according to their age at surgery into two groups: group 1: < 1 year (10 days-12 months, mean 0.2 years) and group 2: > 1 year (1-19 years, mean 9.7 years). A group of age- and sex-matched patients with normal LV function served as controls. LMM was increased late postoperatively in both groups irrespective of the age at surgery and was correlated significantly with the elevated systolic blood pressure and the residual pressure gradient at exercise. End-systolic wall stress was normal at rest and the stress/velocity relationship revealed normal contractility in all patients. Despite successful operation of aortic coarctation, residual LV hypertrophy persists 2 to 19 years after surgery irrespective of the age at surgery. LV systolic function is normal. Hypertrophy can be explained by the residual arm-leg pressure gradient during exercise which persists even after successful repair.
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Affiliation(s)
- O N Krogmann
- Department of Paediatric Cardiology, Heinrich-Heine University, Düsseldorf, Germany
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33
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Krogmann ON, Rammos S, Jakob M, Corin WJ, Hess OM, Bourgeois M. Left ventricular diastolic dysfunction late after coarctation repair in childhood: influence of left ventricular hypertrophy. J Am Coll Cardiol 1993; 21:1454-60. [PMID: 8473655 DOI: 10.1016/0735-1097(93)90323-s] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Left ventricular systolic and diastolic function were evaluated late after successful operation for aortic coarctation in childhood. BACKGROUND Persistent arterial hypertension and left ventricular hypertrophy after coarctation repair might impair left ventricular function. METHODS Biplane angiography and simultaneous high fidelity pressure measurements were performed in 12 patients 3 to 12 years postoperatively (residual pressure gradient 4 mm Hg). Eight patients were normotensive and four had borderline hypertension. Data at rest and after nitroprusside infusion (1.7 micrograms/kg per min) were evaluated and compared with data from 12 control subjects. RESULTS Systolic left ventricular function (ejection fraction-end-systolic wall stress relation) was normal in all patients. However, left ventricular muscle mass (113 vs. 86 g/m2), right atrial pressure (5.2 vs. 1.9 mm Hg) and left ventricular end-diastolic pressure (16 vs. 11 mm Hg) were significantly higher in patients than in control subjects. There was a linear relation between muscle mass and left ventricular end-diastolic (r = 0.66, p < 0.001) or right atrial (r = 0.60, p < 0.01) pressure. Left ventricular relaxation and myocardial stiffness were normal. However, there was an upward shift of the diastolic pressure-volume curve when compared with control values, but this shift was reversed by the administration of nitroprusside. CONCLUSIONS Systolic function is normal late after coarctation repair. However, diastolic function can be abnormal with an upward shift of the diastolic pressure-volume curve that is reversed by nitroprusside administration and is probably due to residual left ventricular hypertrophy.
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Affiliation(s)
- O N Krogmann
- Department of Pediatric Cardiology, Heinrich-Heine University, Düsseldorf, Germany
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Krogmann ON, Rammos S, Heusch A, Bourgeois M. [Arrhythmias in childhood]. Monatsschr Kinderheilkd 1992; 140:F83-97. [PMID: 1470183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- O N Krogmann
- Klinik für Kinderkardiologie, Heinrich-Heine-Universität Düsseldorf
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Kramer HH, Rammos S, Krian A, Krogmann O, Ostermeyer J, Korbmacher B, Buhl R. Intermediate-term clinical and hemodynamic results of the neonatal arterial switch operation for complete transposition of the great arteries. Int J Cardiol 1992; 36:13-22. [PMID: 1428248 DOI: 10.1016/0167-5273(92)90103-a] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We prospectively evaluated 49 consecutive hospital survivors of the arterial switch operation for complete transposition and intact ventricular septum by clinical examination, echocardiography, cardiac catheterization, 12-lead and 24-h Holter ECG. The mean length of follow-up was 40 +/- 18 months. Forty-six children are clinically asymptomatic without medication, 2 died due to coronary related left ventricular dysfunction 3 and 12 months after surgery, and 1 required reoperation because of severe bilateral pulmonary branch stenoses. Except for this case, cardiac catheterization (n = 23) revealed a mean gradient of only 17 +/- 8 mmHg between the right ventricle and distal pulmonary arteries. Left ventricular end-diastolic volume was within normal limits except for 2 cases with volumes slightly below normal, the mean ejection fraction was 78 +/- 5%, and end-diastolic and end-systolic ventricular shapes were normal. The mean cardiac index was 4.14 +/- 0.69 l/min/m2. Left ventricular end-systolic wall stress to velocity of fiber shortening relation was normal in all cases examined (n = 15), indicating normal myocardial contractility. Significant neoaortic valve insufficiency was never observed despite considerably enlarged aortic roots. Twenty-four-hour Holter ECG records (n = 46) provided no evidence of serious atrial arrhythmias, especially sinus node dysfunction. These encouraging intermediate-term results make the arterial switch operation the treatment of choice at present, for neonates with simple transposition.
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Affiliation(s)
- H H Kramer
- Department of Pediatric Cardiology, Heinrich-Heine University, Düsseldorf, Germany
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Krogmann ON, von Kries R, Rammos S, Kramer HH, Bourgeois M. Left ventricular thrombus in a 2-year-old boy with cardiomyopathy: lysis with recombinant tissue-type plasminogen activator. Eur J Pediatr 1991; 150:829-31. [PMID: 1743212 DOI: 10.1007/bf01955000] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A 2-year-old boy with cardiomyopathy and clinical signs of cardiac failure presented with an echodense structure in the left ventricle. This structure was seen from different echocardiographic views adjacent to a hypokinetic area of the apex and lateral free wall. It was different in texture and motion from the underlying myocardium and thus met the diagnostic criteria of a left ventricular thrombus. This thrombus protruded into the cavum and was partly mobile. In view of a high embolic risk, thrombolytic therapy with recombinant tissue plasminogen activator was started. The thrombus resolved within 72 h without any embolic or bleeding complications. No recurrence of the thrombus was observed during a 3-month follow up period.
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Affiliation(s)
- O N Krogmann
- Department of Paediatrics, Heinrich Heine Universität, Düsseldorf, Federal Republic of Germany
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Kramer HH, Rammos S, Krogmann O, Nessler L, Böker S, Krian A, Bircks W. Cardiac rhythm after Mustard repair and after arterial switch operation for complete transposition. Int J Cardiol 1991; 32:5-12. [PMID: 1864669 DOI: 10.1016/0167-5273(91)90038-q] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We compared the prevalence of arrhythmias among the first consecutive 45 patients with complete transposition (concordant atrioventricular and discordant ventriculo-arterial connexions) after arterial switch operation and the last 47 patients after Mustard repair in infancy. Both groups had 24-hour Holter electrocardiographic studies at similar periods of follow up (24 +/- 14 and 25 +/- 18 months). A second group of patients undergoing the Mustard procedure had been repaired at an older age before 1981. They were studied to determine the frequency of disturbances of rhythm during later postoperative follow-up (85 +/- 24 months). Symptomatic brady-/tachyarrhythmia syndrome never occurred after the arterial switch and only once in the group of patients repaired by the Mustard procedure in infancy, but developed at a late stage (69 +/- 28 months); five times in the group of patients having Mustard's repair at an older age. In addition, Holter monitoring did not detect bradyarrhythmias indicating sinus node dysfunction in a single patient after the arterial switch, but did so to a similar extent in both groups having the Mustard procedure (recent: n = 14; older: n = 18). Three cases of the group of older patients undergoing a Mustard operation developed complete atrioventricular block during follow-up. Normal findings were present in 93% of the cases after arterial switch, but in only 51% of the cases with a similar follow-up repaired by the Mustard procedure, and in 29% of the group having the Mustard repair at an older age.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H H Kramer
- Department of Pediatric Cardiology, Heinrich-Heine-Universität, Düsseldorf, F.R.G
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Abstract
If embryonic communications exist between the splanchnic and cardinal venous systems, then they can explain variations in partially or completely abnormal pulmonary venous return as seen in congenitally malformed hearts. With this in mind, we investigated complete serial sections of 52 human embryos, ranging from 4.4 to 25 mm crown-rump length (Streeter's horizons XIII-XXII) and 57 mouse embryos (Mus musculus albus CPB-S) from 7.8 to 19.7 days of gestation. Specifically, we investigated whether communications persisted between the splanchnic, the pulmonary and the cardinal venous systems. In the early stages of development, the pulmonary vascular bed shared the route of drainage of the peripheral splanchnic plexus into the umbilical-vitelline and cardinal venous systems. As the pulmonary plexus developed, it obtained a new direct route of drainage into the left atrium via the pulmonary veins. A persistence of embryonic connexions was encountered in one human and 14 mouse embryos. In all these cases, the stage of development was such that the connexions between the splanchnic and pulmonary plexuses should have disappeared. An abnormality in the development of the central pulmonary venous system was also found in the human embryo. Whether this was primary or secondary to the persistence of the embryonic connexions remained unresolved.
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Affiliation(s)
- S Rammos
- Department of Pediatric Cardiology, Heinrich-Heine University of Düsseldorf, F.R.G
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39
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Abstract
Birth weights of 843 children with congenital heart disease (CHD) were compared to the respective data of a normal West German population. On average, the CHD group had significantly lower birth weights, but the weight deficit was far less pronounced than in previous studies. The decrease in birth weight was distinct only in children with tetralogy of Fallot and atrial septal defect. Compared to normal newborns, patients with CHD were more often small for gestational age (15.0%) or had a low (less than 2500 g) birth weight (8.6%). The prevalence of prematurity was not increased. Extracardiac malformations were not significantly more common in CHD patients, who were small for gestational age, than in CHD patients with normal birth weight.
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Affiliation(s)
- H H Kramer
- Department of Paediatric Cardiology, Heinrich Heine University, Düsseldorf, Federal Republic of Germany
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40
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Jacob B, Haarhoff K, Neuen-Jacob E, B�rrig K, Frenzel H, Rammos S, Bonte W. Unexpected infant death attributable to cardiac tumor or cardiomyopathy. Int J Legal Med 1990. [DOI: 10.1007/bf00204454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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41
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Jacob B, Haarhoff K, Neuen-Jacob E, Bürrig KF, Frenzel H, Rammos S, Bonte W. Unexpected infant death attributable to cardiac tumor or cardiomyopathy. Immunohistochemical and electron microscopical findings in three cases. Z Rechtsmed 1990; 103:335-43. [PMID: 2162615 DOI: 10.1007/bf01263038] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The pathological findings, including immunohistochemical and electron microscopical findings, in three infants who died unexpectedly of cardiac tumor or cardiomyopathy are reported. The first was a 13-month-old boy with tuberous sclerosis and multiple rhabdomyomas of the heart, who presented with a postpartal cardiac murmur and moderate cardiomegaly. The further history was unknown. The rhabdomyoma nodules were composed of spider cells containing small amounts of desmin and myosin as well as isolated myofibrils. Microscopically small glioma nodules contained high amounts of GFAP. The second case, a boy 4 months of age, died of a large benign fibrous histiocytoma of the heart after an uneventful history. Tumor cells contained alpha-1-anti-chymotrypsin and lysozyme. The third case, a girl 2 months of age, died unexpectedly of histiocytoid cardiomyopathy. The affected cells contained fat droplets, glycogen granules, many leptomer myofibrils and small amounts of myosin and desmin.
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Affiliation(s)
- B Jacob
- Institute of Legal Medicine, Heinrich-Heine-University Düsseldorf, Federal Republic of Germany
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Rammos S, Kramer HH, Trampisch HJ, Krogmann ON, Kozlik R, Bourgeois M. [Normal values of the growth of the pulmonary arteries in children. An angiography study]. Herz 1989; 14:348-57. [PMID: 2620897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Systolic and diastolic diameters of the pulmonary artery anulus (PA-A), pulmonary artery sinus (PA-S), pulmonary artery trunc (PA-St), as well as those of the right and left pulmonary arteries (RPA, LPA) were measured from cineangiograms of 51 infants, children and adolescents without heart disease (n = 16) or with cardiovascular malformations which had no hemodynamic relevance (n = 35). The following diagnostic categories were included in the normal group: pulmonary stenosis (n = 16), bicuspid aortic valve (n = 4) or subvalvular aortic stenosis (n = 2), all with a systolic gradient lower than 15 mm Hg, aberrant innominate artery (n = 5), small PDA (n = 3) or small VSD (n = 2) and patients with Kawasaki disease without coronary aneurysms (n = 3). The patients were sedated and studied in a fasting state and in the supine position. Angiocardiographies were performed in the right ventricle or/and in the pulmonary artery. A grid or the known diameter of the catheter was used for calibration purposes. The corresponding systolic and diastolic diameter values were averaged in order to obtain a mean diameter of each vascular segment. All measurements were correlated with the body length and the body surface area (BSA). A root exponential function [square root of y = a(1 - e-bx) + c] was used, the regressions coefficients of which can be explained by physiological means. In this function c2 is the theoretical minimal diameter and (a + c)2 the theoretical maximal diameter of a cardiovascular structure; in this way the growth of the cardiovascular dimensions could be well defined mathematically and correlated strongly (r = 0.99) with body length and BSA. Different exponents were found for the pulmonary artery anulus, sinus, trunc as well as right and left pulmonary arteries. All the diameters showed a systolic increase between 8 to 10% above diastolic measurements. The anulus had an average diameter 16% smaller than the sinus and 9% than the distal region of the pulmonary artery; the right pulmonary artery was 7% larger than the left. A limitation of the study was that the diameters were measured in single projections only, necessitating the assumption of a circular cross section of the cardiovascular structures. The angiographically determined PA-A was larger than those of formaldehyd-fixed hearts. This finding indicates that the fixation method may alter the anatomic structures probably due to shrinkage process. PA-S measurements were closest to echocardiographic diameters measured by other authors.
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Affiliation(s)
- S Rammos
- Abteilung für Kinderkardiologie, Heinrich-Heine-Universität Düsseldorf
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Rammos S, Kramer HH, Trampisch HJ, Kozlik R, Krogmann ON, Bourgeois M. [Normal values of the growth of the aorta in children. An angiography study]. Herz 1989; 14:358-66. [PMID: 2620898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Angiocardiography is a standard procedure for quantification and evaluation of congenital heart disease. Knowledge of the diameters at the level of aortic valve ring, ascending and descending aorta can contribute to the decision in repair of congenital heart disease. Moreover, they are helpful for postoperative follow-up studies. In order to establish normal standards, analysis was performed on 51 cineangiograms obtained from infants, children and adolescents with no evidence of heart disease (n = 16) or only hemodynamically irrelevant cardiovascular malformations (n = 35). The individual diagnoses in these patients appear in the accompanying publication in this issue. Patients with bicuspid aortic valve or subvalvular aortic stenosis were excluded from measurements of the aortic valve ring, the sinus and the ascending aorta. Angiocardiography was performed in a fasting state, after sedation and in the supine position with injections of contrast material in the pulmonary artery and or in the left ventricle and ascending aorta. For purposes of calibration, a grid or the known diameter of the catheter was used. Systolic and diastolic diameters of the aortic valve ring (AO-R), sinus (AO-S) and distal region, between sinus valsalvae and ascending aorta (AO-D), as well as those of the isthmus (DAO-I), postisthmic region (DAO-PI) and descending thoracoabdominal aorta (DAO-T) were measured. To obtain a mean value for each vascular structure, the corresponding systolic and diastolic diameters were averaged. The mean diameter was referenced to body length and body surface area (BSA).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S Rammos
- Abteilung für Kinderkardiologie, Heinrich-Heine-Universität Düsseldorf
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de Ruiter MC, Gittenberger-de Groot AC, Rammos S, Poelmann RE. The special status of the pulmonary arch artery in the branchial arch system of the rat. Anat Embryol (Berl) 1989; 179:319-25. [PMID: 2735526 DOI: 10.1007/bf00305058] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A renewed study of the development of the branchial arch system was essential in view of the special morphologic characteristics of the ductus arteriosus, which derives from the pulmonary arch artery or sixth branchial arch artery. In congenital heart disease certain aorto-pulmonary collateral arteries have a marked histological similarity to the ductus arteriosus. To gain a better insight into the development of these vessels, 27 rat embryos, with the number of somites ranging between 19 and 41, were studied. Most embryos were collected after shortterm in vitro-culture, allowing precise staging of age and development. The vascular system of these embryos was injected with Indian ink, to enable easy recognition of even the smallest endothelium-lined vessels. The embryos were serially sectioned (3-5 microns) and reconstructed using a graphic method. The results show that the pulmonary arch artery differs from the other arch arteries in that it is the most cranial vessel of a system of ventral splanchnic arteries, which connects the pulmonary plexus with the dorsal aortae at an early stage. With the exception of the pulmonary arch artery, these connections are transient. The pulmonary arteries develop from the remaining parts of the plexus. It is argued that these connections can persist in the human as aorto-pulmonary collaterals, in certain cases with abnormalities in the pulmonary part of the cardiac outflow tract.
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Affiliation(s)
- M C de Ruiter
- Department of Anatomy and Embryology, University of Leiden, The Netherlands
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45
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Abstract
We prospectively examined 1016 infants and children with congenital heart disease (CHD) to detect additional malformation patterns. They were divided into two major groups. In the first group (n = 881), the CHD either occurred alone or was accompanied by a major extracardiac malformation (n = 68, 7.7%). In the second group (n = 135, 13.3%), the CHD was part of a malformation syndrome, embryopathy, association, or complex. In one fourth of the 56 chromosomal syndromes, the underlying cytogenetic anomaly differed from trisomy 21. Fourteen of the 30 children with non-chromosomal malformation syndromes had Noonan's syndrome. Thirteen of the 27 embryopathies were due to rubella infection, but alcohol embryopathy occurred nearly as often (n = 10). In those children with malformation associations (n = 16) seven showed cardiofacial association. Three of the five children with malformation complexes had Ivemark disease. In this study, underlying disorders were found in one of eight children with CHD, a considerably higher percentage than that reported in earlier studies.
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