Increased satisfaction of maternity hospital staff involved in fetal telediagnosis

Questionnaires were sent to 14 maternity hospital staff members for qualitative assessment at the start of fetal telediagnosis and at the end of the study using a five-point Likert scale: 5, I strongly think so; 4, I think so; 3, I can't decide; 2, I don't think so; 1, I never think so. Ten questionnaires were returned to us (71%). The results showed that the staff reported a significant increase in confidence in performing fetal cardiac screening (score 2.3 at start, 3.4 at study completion; P = 0.034), the rate of score increase rose with the number of telediagnoses (r = 0.72, P < 0.05), feedback from a specialist was very useful (4.4 and 4.9, respectively), and real-time image transmission was preferred over recorded images (score 3.7 vs 2.4, respectively; P = 0.042). The excellent educational effect of telemedicine is useful for staff members to improve their skills while nurturing their motivation, leading to the promotion of fetal cardiac screening in regional areas.

A medical link between local maternity hospitals and a tertiary center using telediagnosis with fetal cardiac ultrasound image transmission

Information and communication technology has been widely applied to various fields, including clinical medicine. We report here a telediagnosis system using ultrasound image transmission. The effect of telediagnosis, using a medical link between local maternity hospitals and our children's medical center, was verified. The number of fetal telediagnosis for cardiac disease, and cases referred to a perinatal care center and emergent transportation of neonates with congenital heart disease from maternity hospitals, were calculated based on the hospital records. The percentage of patients found to have heart disease was compared between out-patient clinic and telediagnosis cases. Telediagnosis increased, allowing maternity hospital staff to obtain support easily from a specialist when making a diagnosis. Many severe cases were transferred to tertiary centers with the correct diagnosis; consequently, the number of emergent transportations of neonates with severe cardiac anomalies continued to below. Telediagnosis was also useful as an educational tool for maternity hospital staff, who improved their skills during conversations with a specialist. Unlike in the outpatient clinic, consultation by telediagnosis was requested even for cases of mild abnormalities, and the number of false-positives increased, while many cardiac anomalies were found in the early stage. Furthermore, telediagnosis was helpful for pregnant women requiring bed rest, and also had the advantage of allowing a doctor to be able to talk with parents. Establishing a fetal telediagnosis system is a useful strategy to improve neonatal care through a medical link between local maternity hospitals and a tertiary center.

Accuracy of telediagnosis of fetal heart disease using ultrasound images transmitted via the internet

We verified the feasibility of telediagnosis of fetal disease by (i) grading telediagnosis by a pediatric cardiologist into five confidence levels; and (ii) comparison of fetal telediagnosis with hands-on fetal diagnosis or postnatal diagnosis. In 114 patients suspected of having heart disease (real time, n = 15; recorded image transmission, n = 99), 79 patients were in level 5 (excellent), 17 in level 4 (good), eight in level 3 (fair), 10 in level 2 (poor), and no patients in level 1 (bad). The average was 4.5, and in 96 patients (84% of all) telediagnosis was accurate (above 4), whereas in 18 patients it was inaccurate (level 2 or 3). In re-examination of 25 patients, telediagnosis was confirmed in patients in level 4 and 5, whereas heart disease was missed in patients in levels 2 or 3. The correct diagnosis matched the high confidence level of a specialist based on recognizable transmitted images.

Successful uses of magnesium sulfate for torsades de pointes in children with long QT syndrome

BACKGROUND

Administration of magnesium sulfate (MgSO4) is an effective and safe treatment for torsades de pointes (TdP) associated with acquired long QT syndrome (LQTS) in adults. As for children, there are few reports focusing on it. The authors discuss the efficacy of MgSO4 for TdP in children with congenital and acquired LQTS. The authors also discuss the optimal administration dosage and serum magnesium (SMg) concentration during MgSO4 therapy.

METHODS

The authors studied seven consecutive LQTS children undergoing MgSO4 therapy for TdP. Of the seven children, five were congenital LQTS and two were acquired LQTS. A bolus injection of MgSO4 was given intravenously over 1-2 min followed by continuous infusion for the next 2-7 days.

RESULTS

Of the seven patients, six responded completely to the initial bolus. The bolus dosage was 5.9 +/- 3.8 mg/kg (range, 2.3-12 mg/kg) in these six, and the other remaining one (neonate with congenital LQTS) required a total of 30 mg/kg until complete abolishment. The continuous infusion was given at rates of 0.3-1.0 mg/kg per h and patients did not show recurrence of TdP. The SMg concentration was 3.9 +/- 1.0 mg/dL (2.9-5.4 mg/dL) immediately after bolus injection. The mean corrected QT (QTc) interval before and after bolus injection did not show significant difference.

CONCLUSION

Intravenous infusion of MgSO4 was effective for TdP in children with LQTS, and MgSO4 abolished TdP without shortening the QTc interval. The optimal bolus dosage, infusion rates and SMg concentration were 3-12 mg/kg, 0.5-1.0 mg/kg per h and 3-5 mg/dL, respectively.

Optimal Administration Dosage of Magnesium Sulfate for Torsades de Pointes in Children with Long QT Syndrome

BACKGROUND

Intravenous administration of magnesium sulphate (MgSO(4)) is a very effective and safe treatment for torsades de pointes (TdP) associated with acquired long QT syndrome (LQTS) in adults. Discussed here is the efficacy of MgSO(4) for TdP in children with congenital and acquired LQTS.

METHODS

The optimal MgSO(4) dosage and serum magnesium (SMg) was determined in six consecutive children with TdP; four had congenital LQTS and two had acquired LQTS. A bolus injection of MgSO(4) was given intravenously over 1 to 2 minutes followed by continuous infusion for the next 2 to 7 days.

RESULTS

Of the six patients, five responded completely to the initial bolus of 6.1 +/- 4.2 mg/kg (range, 2.3-12 mg/kg). One (a neonate with congenital LQTS) required a total of 30 mg/kg until complete TdP elimination. Continuous infusion was given at rates of 0.3 to 1.0 mg/kg/hr with no recurrence of TdP. SMg concentration was 3.9 +/- 1.0 mg/dL (2.9-5.4 mg/dL) immediately after bolus injection.

CONCLUSION

Intravenous MgSO(4) infusion effectively treated TdP in children with LQTS. Optimal bolus dosage, infusion rates and SMg concentration were 3 to 12 mg/kg, 0.5 to 1.0 mg/kg/hr and 3 to 5 mg/dL, respectively.

Diagnosis and outcome of dextrocardia diagnosed in the fetus

A retrospective review of 5,539 fetal echocardiograms over a 22-year period revealed 85 cases of dextrocardia. In primary dextrocardia (46 cases), the incidence of situs solitus, inversus, and ambiguous, was similar and associated with a high incidence of complex cardiac malformations in situs solitus and situs ambiguous. Secondary dextrocardia (39 cases) was due to intrathoracic displacement and, when caused by diaphragmatic hernia, was associated with cardiac malformations in 31% of cases. Even in complex cases, fetal echocardiography was highly accurate; therefore, specific counseling can be given to parents.

A novel Doppler echocardiographic method of measuring the biophysical properties of the aorta in pediatric patients

BACKGROUND

This study was performed to: (1) assess the feasibility of measuring pulse wave velocity (PWV) from aortic (AO) Doppler flow and deriving AO input and characteristic impedances and the arterial pressure strain elastic modulus; and (2) compare these indices in pediatric patients with arterial disease to control (C) patients.

METHODS

There were 14 healthy children in the C group, 9 with inflammatory connective tissue diseases (ICTD), and 6 with Marfan syndrome (M). Using standard echocardiographic equipment, the AO annulus, AO root diameter in systole (AO(S)) and diastole (AO(D)), and AO length (L) were measured. The time taken for the Doppler signal to travel from the ascending to descending aorta was measured. AO peak flow was calculated from AO annulus cross-sectional area x peak aortic velocity (AoV); PWV = L/time taken for the Doppler signal to travel from the ascending to descending aorta; input impedance = (systolic - diastolic blood pressure)/(AO cross-sectional area x AoV); characteristic impedance = (PWV x rho)/Ao cross-sectional area (where rho = 1.06); and pressure strain elastic modulus = (systolic - diastolic blood pressure)/[(AO(S) - AO(D))/AO(D)]; beta index = ln (systolic/diastolic blood pressure)/[(AO(S) - AO(D))/AO(D)].

RESULTS

Results for PWV were ICTD = M > C (533, 496, 362 cm/s; P <.02); for input impedance were ICTD > M = C (245, 120, 116; P <.03); for characteristic impedance were ICTD < M = C (249, 107, 142; P <.05); for pressure strain elastic modulus were M > ICTD = C (262, 447, 187; P <.003); and for beta index were M > ICTD > C (2.91, 2.51, 2.13; P <.0006).

CONCLUSIONS

This novel, relatively simple method of assessing the biophysical properties of the aorta shows abnormal function in patients with M and ICTD. This technique may be helpful in the long-term follow up of patients with arterial disease.

Lobar emphysema due to ductus arteriosus compressing right upper bronchus in an infant with congenital heart disease

A 1-month-old boy with tetralogy of Fallot, pulmonary atresia, right aortic arch, and right ductus arteriosus, exhibited progressive right upper lobar emphysema since his birth. The emphysema was caused by the right ductus arteriosus compressing the right upper bronchus. After division of the ductus arteriosus the emphysema completely regressed. We should explore the cause of lobar emphysema thoroughly before lobectomy especially when it is extrinsic. The emphysema may regress by eliminating the extrinsic factor.

Influence of heart surgery on magnesium concentrations in pediatric patients

BACKGROUND

There have been only a few investigations into the effects of cardiopulmonary bypass (CPB) on the magnesium (Mg) concentrations in pediatric patients. The purpose of the present study was to compare the postoperative Mg concentrations and their recovery time to pre-surgical values in pediatric patients undergoing CPB for surgical repair of congenital heart disease. The incidence of dysrhythmia was also determined.

METHODS

Twenty-seven pediatric patients undergoing open-heart surgery with CPB were enrolled in this study. Controls were 23 pediatric patients undergoing palliative surgery without CPB. Serum Mg (SMg) concentrations and ionized Mg (iMg) concentrations were measured at four sample points: 24 h before the surgery, immediately after the surgery, 24 h after the surgery and 48 h after the surgery.

RESULTS

Serum Mg and iMg concentrations were significantly decreased after open-heart surgery. Immediately after the surgery, the mean SMg concentration was 64.1% and the mean iMg concentration was 68.8% of the pre-surgical values. The concentration of iMg showed quicker recovery than that of SMg, and returned to normal range 48 h after surgery. However, SMg and iMg concentrations after palliative surgery did not show significant differences from the pre-surgical values. The incidence of dysrhythmia was almost the same between the two groups; dysrhythmia was observed in two patients in the open-heart surgery group and in three patients in the palliative surgery group.

CONCLUSIONS

Mg concentrations showed significant decrease after CPB; however, they showed quick recovery and did not increase the incidence of dysrhythmia in pediatric patients.

Perioperative course in two cases of tetralogy of fallot with portal venous atresia

We report here two rare surgical cases of tetralogy of Fallot with portal venous atresia. Both patients, previously diagnosed with tetralogy of Fallot, developed portal hypertension and showed hematemesis and/or melena. One patient needed endoscopic sclerotherapy. Intracardiac repair was performed under cardiopulmonary bypass (CPB) with moderate hypothermia. After surgery, one of the patients developed cardiogenic shock due to cardiac tamponade with accumulated chyle in the pericardial sac in the ninth postoperative day, and showed deteriorated liver function, suggesting that liver might have been vulnerable because of the absence of portal blood.

Studies of magnesium in congenital long QT syndrome

We studied the role of magnesium (Mg) in congenital long QT syndrome (LQTS). Twenty-two congenital LQTS patients and 30 control subjects were included in this study. We measured serum Mg (SMg) level and Mg retention (MgR) level, and evaluated the role of Mg (a high MgR level reflects Mg deficiency in the body). The influence of intravenous Mg infusion on Mg level was evaluated. Relatively low SMg level and high MgR level (LQTS:control = 53:33%, p < 0.01) were recognized in congenital LQTS patients, but there was an overlap with controls. Mg supplementation did not shorten QT interval and there was no significant correlation between Mg levels and QTc interval. Patients with syncopal history showed a higher MgR level (syncope (+):syncope (-) = 70:46%, p < 0.01) and intravenous Mg infusion improved Mg deficiency. These results suggest that some (not all) congenital LQTS patients are in a Mg-deficient state, which may be associated with syncope, and Mg supplementation may prevent recurrent syncope in these patients. Because there are several subtypes of congenital LQTS, perhaps with genetic testing Mg deficiency may be identified as a significant cofactor in some forms, whereas in other forms it is not relevant.

Characteristics of improved NOVA magnesium ion-selective electrode: changes of ionized magnesium values and reference interval in healthy children

Following the report of interference between the thiocyanate ion (SCN-) and NOVA's previous ion-selective electrode (ISE) for ionized magnesium (iMg2+), NOVA has developed a new ISE which eliminates the effect of SCN-. Two hundred and sixty healthy children were divided into two groups; those who had presented when using NOVA's previous ISE (group A; n = 160) and those using NOVA's new ISE (group B; n = 100). The mean iMg2+ value and the mean iMg2+ percent fraction (iMg2+/serum Mg) were significantly higher in group B than in group A (0.59 +/- 0.03 vs 0.54 +/- 0.03 mmol/L for iMg2+; p < 0.001 and 64.8 +/- 3.1 vs 58.2 +/- 4.1 per cent for iMg2+ percent fraction; p < 0.001). The mean serum SCN- level was 0.023 +/- 0.008 mmol/L in group A (n = 8) and 0.0.21 +/- 0.007 mmol/L in group B (n = 12), and was not significantly different between the two groups. The suspected change of iMg2+ value interfered by SCN- was 0.037 mmol/L in group A. The difference of iMg2+ percent fraction between two groups was higher at high serum magnesium (SMg) levels. The reference interval of iMg2+ was 0.56-0.62 mmo/L in healthy children with the NOVA's new ISE, and was constant irrespective of growth. The NOVA's previous iMg2+ ISE may be interfered with mainly by SCN-. The newly designed ISE eliminated these effects especially at higher SMg levels.

Malignant fibrosarcoma with features of myxoma

Left atrial tumor, diagnosed as myxoma at first investigation, was later demonstrated to be a malignant fibrosarcoma with myxoid change. Myxoma should be diagnosed and managed carefully because of its wide range of histopathologic features.

Surgical ligation of anomalous hepatic vein in a case of heterotaxy syndrome with massive intrahepatic shunting after modified fontan operation

In case of progressive cyanosis after modified Fontan procedure, intrahepatic shunting should be considered. Ligation of the hepatic vein is safe and effective in managing this condition, and it is important to ensure that the pressure difference between superior vena cava and the portal vein system remains minimal after clamping of the hepatic vein before ligation is completed to minimize the possibility of varix due to portal vein hypertension.

Hypoplastic left heart syndrome: duration of survival without surgical intervention

BACKGROUND

Mortality rate for heart transplantation for patients with hypoplastic left heart syndrome (HLHS) has improved, but there is a considerable wait until a suitable donor is available. Thus it is important to examine the duration of survival and risk factors for early death in patients with HLHS who did not undergo surgical intervention.

METHODS AND RESULTS

Twenty-six consecutive patients were studied retrospectively. Duration of survival and the 14 following variables were investigated: date of birth, body weight at birth, cardiothoracic ratio, ascending aorta diameter, interatrial communication size, coarctation of the aorta, tricuspid regurgitation, anatomic subtype (patency) of mitral and aortic valve, arterial blood gas findings (pH, PaO 2, SaO 2, PaCO2, base excess), and ST depression in the electrocardiogram. Twenty patients survived <60 days (group A) and 6 patients survived beyond 60 days (group B). The duration of survival (mean [SD]) was 60 (151) days overall (1 patient is currently alive at 783 days). The long-term survivors (beyond 60 days) increased significantly after 1991 (P <.05). Coarctation of the aorta was a significant risk of early death (<60 days) (P <.05). Interatrial communication size was significantly smaller in group B than in group A (P <.05). The mean pH and base excess were significantly lower in group A than in group B. The other 9 variables showed no significant difference between the 2 groups.

CONCLUSIONS

There was a significant correlation of long-term survival with stabilized ductal blood flow without coarctation of the aorta, adequate restriction of interatrial communication without severe hypoxemia, and no metabolic acidosis.

Rapid enlargement of cardiac rhabdomyoma during corticotropin therapy for infantile spasms

OBJECTIVE

To investigate the influence of corticotropin therapy on cardiac rhabdomyoma.

DESIGN

Analysis of data from echocardiography performed on in-patients.

PATIENTS

Six patients with rhabdomyoma who were admitted to the authors' medical centre with either convulsion (five cases) or prematurity (one case) between 1985 and 1995. Five had tuberous sclerosis.

INTERVENTION

Size of cardiac tumours of each patient was measured by echocardiography, and volume index was calculated as the ratio of the tumour volume to its initial volume.

MAIN RESULT

Increase in size of some of the tumours was found during corticotropin therapy on follow-up echocardiography. Maximum volume indexes of tumours in the case of patients (n = 4) who did not receive corticotropin therapy was 1.2 to 3.7, whereas those of patients (n = 2) who received therapy was 9.1 to 12; one of the latter patients died.

CONCLUSION

Corticotropin may contribute to the enlargement of cardiac rhabdomyoma. The size of cardiac rhabdomyomas must be carefully followed when patients are treated with corticotropin.

[Superior vena cava-right atrial appendage direct anastomosis for repair of partial anomalous pulmonary venous connection to superior vena cava]

Successful repair was performed for a 7-year-old male with a diagnosis of partial anomalous pulmonary venous connection (PAPVC) to superior vena cava (SVC) and superior sinus venosus atrial septal defect (ASD). The SVC was divided above the orifice of the anomalous pulmonary vein and the cephalad end of the SVC was anastomosed directly to the right atrial appendage. A patch was used to divert pulmonary venous flow from the orifice of the SVC through superior sinus venosus ASD into the left atrium. Postoperative course was uneventful with normal sinus rhythm. There was no evidence of vena caval or pulmonary venous obstruction. At 3-month after surgery, sinus node function was confirmed to be normal by electrophysiological study. This is useful alternative method for repair of PAPVC to high or middle SVC.