Cardiac effects of a single course of antenatal betamethasone in preterm infants

AIM

To show the effects of a single course of antenatal betamethasone on cardiac measurements and systolic functions in premature newborn infants.

METHODS

Seventy six newborn infants with a gestational age of 25-33 weeks were included in the study. They were first classified according to their gestational age: 25-29 weeks (n = 28) and 30-33 weeks (n = 48). They were then reclassified as betamethasone positive (mother received one course of betamethasone) or betamethasone negative (mother did not receive any antenatal glucocorticoid treatment). Cross sectional M mode echocardiographic scans were performed during the first three postnatal days and at the end of the first and third weeks. Left interventricular septum (IVS), left ventricular posterior wall (LVPW), left ventricular end diastolic (LVED), and left ventricular end systolic (LVES) dimensions, aortic root (AO), and left atrial diameters (LAs) were measured. The IVS to LVPW ratio was calculated to identify asymmetrical septal hypertrophy.

RESULTS

In neither group was any statistically significant difference noted in IVS, LVED, LVES, LVPW, LA, and AO measurements during the three cardiac ultrasonography scans. Systolic function, as assessed by fractional shortening, was not significantly different in infants who received betamethasone antenatally, in either age group. There was no difference in the IVS/LVPW ratios between those who received antenatal steroid and those who did not for the 25-29 week and 30-33 week groups during these three consecutive scans.

CONCLUSION

One course of antenatal betamethasone did not affect the cardiac wall thicknesses and systolic function in premature infants.

Aortic valve prolapse and aortic regurgitation in patients with ventricular septal defect

Aortic valve prolapse (AVP) was detected in 82 (7.5%) of 1096 patients with ventricular septal defect (VSD) (in 50 at initial echocardiographic examination and in 32 at follow-up) by echocardiography. Of 82 patients with AVP, aortic regurgitation (AR) was detected in 53 (65%) (in 28 at initial echocardiographic examination and in 25 at follow-up), resulting in an incidence of AR of 4.8% (of VSD). The percentage of AVP (20.8%) and AR (16.7%) in muscular outlet VSDs was larger than the percentage of AVP (10.6%) and AR (6.8%) in perimembranous VSDs (p <0.05). Fourty-four patients were followed medically after AVP appeared (3 months to 10.8 years; median, 2.1 years). Initially, there was no AR in 24 of these patients, trivial AR in 7, and mild AR in 13. Trivial AR developed in 6 (25%) and mild AR developed in 3 (13%) of 24 patients who had no AR (in 5 of them within 1 year and in 9 of them within 2 years). In 2 (29%) of 7 patients, trivial AR progressed to mild AR during a median of 2 years, and in 4 (31%) of 13 patients, mild AR progressed to moderate AR during a median of 1.1 years. We recommend frequent echocardiographic evaluation (every 6 months) for detecting of appearance of AR in patients with perimembranous or muscular outlet VSD after AVP develops and for evaluating the progression of AR in patients with perimembranous or muscular outlet VSD, AVP, and trivial AR. In addition, we recommend surgical intervention in patients with perimembranous or muscular outlet VSD, AVP, and mild AR because of rapid progression of mild AR to moderate AR.

Evolution of ventricular septal defect with special reference to spontaneous closure rate, subaortic ridge and aortic valve prolapse

The medical records of 685 patients with ventricular septal defect (VSD) were reviewed to determine spontaneous closure, left ventricular-to-right atrial shunt, subaortic ridge, and aortic valve prolapse. Patients had been followed for a mean of 3 +/- 2.5 years and median 2.2 years by echocardiography. VSD was perimembranous in 65.7% (450), trabecular muscular in 30.8% (211), muscular outlet in 2.3% (16), muscular inlet in 0.7% (5), and doubly committed subarterial in 0.5% (3). Defect size was classified in 76% (517) as small, in 18% (124) as moderate, and in 6% (44) as large. VSD closed spontaneously in 27% (186 of 685 patients) by ages 40 days to 13.7 years (mean, 2.1 +/- 2.2 years; median, 1.3 years). Sixty-six of 450 perimembranous defects (15%) and 120 of 211 trabecular muscular defects (57%) closed spontaneously (p <0.001). Defect size became small in 15% of patients with VSD at mean 2.9 +/- 2.3 years (median, 2.3 years). Aneurysmal transformation was detected in 56% (254), left ventricular-to-right atrial shunt in 8.4% (38), subaortic ridge in 5.8% (26), aortic valve prolapse in 11.7% (53), and aortic regurgitation in 7.3% (33) of 450 patients with perimembranous defect. There was no statistical significance between the age at closure and the age of detection of aneurysmal transformation in the patients with perimembranous defect (p = 0.25).

Prenatal echocardiographic diagnosis of situs inversus totalis and transposition of the great arteries: a case report

A case of situs inversus totalis and transposition of the great arteries (TGA) was diagnosed prenatally at 25 weeks' gestation. Postnatal echocardiographic examination confirmed the antenatal findings. This case underscores the importance of recognizing situs abnormalities during obstetric and fetal echocardiographic examination, as they are often associated with cardiac anomalies. Accurate prenatal diagnosis of structural heart defects is extremely important in family counselling and in planning obstetric and postnatal treatment.

Antenatal diagnosis of postductal coarctation of the aorta. A case report

Fetal echocardiography can be used to detect congenital heart disease prenatally with a high degree of accuracy, and complex heart malformations have also been clearly described in the fetus. However, it is difficult to diagnose correctly or to exclude definitely aortic coarctation by fetal echocardiography. A 23-year-old woman was referred for fetal echocardiographic examination at 21 weeks' gestation after discovery of hydrops fetalis (nonimmune) on an obstetric ultrasound examination. Aortic isthmus appeared hypoplastic with a diameter < or = 3rd percentile for gestational age. There was a narrowing within the descending aorta immediately distal to the origin of the ductus arteriosus. Color flow imaging demonstrated acceleration and turbulent flow and the peak pressure gradient was measured 83 mmHg by continuous wave Doppler in the same area. The pregnancy terminated in spontaneous abortion at 22 weeks' gestation. The fetus was stillborn. The autopsy findings confirmed the prenatal diagnosis. We conclude that together with the quantitative estimation of the aortic arch, color Doppler and continuous wave Doppler are helpful in diagnosis and estimation of the pressure gradient.

Balloon dilatation angioplasty of stenosed systemic-pulmonary artery shunts

Seven children and an adult patient with cyanotic congenital heart defects underwent balloon dilatation angioplasty (BDA) of a stenosed systemic-pulmonary artery shunt to improve arterial oxygen saturation. We attempted to perform BDA using the transvenous route in all patients in whom the aorta connected with the right ventricle, such as in tetralogy of Fallot or double outlet right ventricle, in an effort to avoid femoral artery injury. We could use the transvenous route (antegrade) in three children with tetralogy of Fallot and in one child with tetralogy of Fallot and pulmonary atresia (one of them was 6.6 kg). Following BDA, there was an increase in arterial oxygen saturation from a mean of 65.9 +/- 12.8% to a mean of 78.1 +/- 8.3% (p < 0.05). On follow-up three to 37 months (mean 16.5 +/- 11.2 months) after BDA, the condition of all patients had improved. Pulmonary hypertension developed in one patient during the follow-up period. It is concluded that BDA of stenosed systemic-pulmonary artery shunts is reasonable, effective and safe. Use of the transvenous route, if possible, to perform balloon dilatation angioplasty facilitates the safe advancement of the larger balloons in low-weight children.

Accessory mitral valve tissue causing severe subaortic stenosis with dextrocardia in a premature newborn

We report an unusual case of left-ventricular outflow obstruction caused by accessory mitral valve tissue associated with dextrocardia and ventricular septal defect in a seven-day-old, 2200 grams premature infant, who was referred with a heart murmur. The diagnosis was made by two-dimensional and Doppler echocardiography which demonstrated the accessory tissue as well as a 100 mmHg peak systolic gradient between the left ventricle and the aorta. Ten days after the presentation the infant underwent emergency surgery after respiratory arrest and recurrent episodes of syncope. The accessory mitral valve tissue and its fibrous extension were excised and the ventricular septal defect was closed. We believe that surgical treatment of patients with accessory mitral valve tissue should be performed early because of the possibility of acute deterioration. Combined aortotomy and interatrial approach is very helpful in evaluating the anatomy and the mitral valve function as well as delineating the tissue to be excised.

Scimitar syndrome with absence of the right pulmonary artery: a case report

We report a two-year-old female child with scimitar syndrome associated with absent pulmonary artery but with normal pulmonary artery pressure although several collaterals originated from the abdominal aorta to the right lung. To our knowledge, this is the fifth case with an absent pulmonary artery. Our case also had microphthalmia, an association not previously described in scimitar syndrome.

Echocardiographic diagnosis of sinus Valsalva aneurysm rupture in two pediatric patients

Sinus Valsalva aneurysm rupture (SVAR) is a rare cardiac abnormality that requires surgical correction when diagnosed. Previously, cardiac catheterization and angiography were thought to be necessary for its diagnosis. We present two pediatric cases of SVAR with subarterial ventricular septal defect (VSD) diagnosed noninvasively by echocardiography; surgical findings confirmed the diagnosis. In both of our cases the origin of SVAR was the right coronary sinus. The first case was ruptured into the right ventricular cavity; the second was ruptured into the right ventricular outflow tract. Continuous murmurs heard during follow-up of children with VSD must alert the physician to this pathology. Combined two-dimensional, Doppler and color-Doppler echocardiography is an accurate, noninvasive method for diagnosis of SVAR.

Balloon atrial septostomy under echocardiographic guidance. Case report

A seven-days-old male neonate was transferred to our institution in critically ill condition. Echocardiographic (ECHO) examination revealed the transposition of the great arteries (TGA) with a small ventricular septal defect. In the laboratory examination, arterial oxygen saturation was 29 percent and pH was 7.16. The poor condition of the neonate led us to decide to perform an immediate bedside balloon atrial septostomy (BAS) in the intensive care unit (ICU) with ECHO guidance. The umbilical vein was cannulated with a 5 Fr. Miller BAS catheter. Four balloon passes were performed resulting in large atrial septal defect. After the procedure, arterial oxygen saturation was measured at 40 percent. In TGA, the baby may present with severe hypoxia and may need management in the ICU. Emergency BAS may improve the clinical condition of the patient. Transferring the baby, who is mechanically ventilated (and is in openbed), to the catheterization laboratory takes time and can be harmful for him, and carries risk of extubation and heat loss. The limitations of transthoracic ECHO guidance of BAS include the possibility of a poor ECHO window in an ill neonate on assisted ventilation and possible interference with maneuverability for both echocardiographer and catheter operator. It also carries the risk of contamination of the sterile field. When the advantages and disadvantages of transthoracic ECHO guidance are considered, transferring the baby to the catheterization laboratory can cause problems and time loss. Thus, ECHO-guided BAS at bedside is an efficient and good alternative. The transumbilical approach may be easier in the first few days of life.

Left ventricular size following shunt operation in tetralogy of Fallot

This study was performed in 24 patients with tetralogy of Fallot in whom shunt operation was performed instead of total correction because of small left ventricular end-diastolic dimension. Left ventricular end-diastolic dimension was measured using M-mode and two-dimensional echocardiography pre- and at least one year postoperatively. There was no change in the postoperative left ventricular size in two patients. However, in the other 22 patients, the left ventricular dimension was increased to 70 to 103 percent of normal left ventricular size. According to the findings of this study, we can conclude that the patients in whom shunt operation was performed would most likely have an increased left ventricular size over time.

Fixed subaortic stenosis in childhood. Medical and surgical course in 90 patients

This study evaluated diagnostic criteria, clinical observations, surgical indications and complications in 90 cases of fixed subvalvular aortic stenosis. Echocardiography, catheter angiography and surgical findings indicated that 60 (66.6%) patients had subvalvular membranous stenosis, 20 (22.2%) patients had fibromuscular stenosis, 4 (4.4%) patients had membranous and fibromuscular stenosis, and 6 (6.6%) had a tunnel-type obstruction. Forty-two patients had additional cardiac anomalies, such as PDA, valvular aortic stenosis and VSD. Fifty patients were treated surgically. Thirty-six patients were evaluated by two-dimensional and Doppler echocardiography at post-surgical intervals ranging from 7 days to 11 years (mean 3.6 years). There were pathological echo findings in 12 patients. The prognosis of this anomaly depends upon early diagnosis and treatment. The results of this study support the importance of the two-dimensional and Doppler echocardiography in early diagnosis and follow-up of the surgical results in treatment of this anomaly.

Left ventricular thrombosis due to acquired protein C deficiency diagnosed by two-dimensional echocardiography

We present a patient with left ventricular thrombus diagnosed by two-dimensional echocardiography. Thrombosis was due to acquired transient protein C deficiency which was caused by impaired liver function due to hepatitis, sepsis and heart failure. With proper treatment the thrombus disappeared on the fourth day. Eighteen weeks later the protein C level returned to normal. We recommend echocardiographic evaluation and follow-up of suspected cases for intracardiac thrombus. The measurement of protein C level in such cases is proposed. This is the first case with left-sided cardiac thrombus associated with protein C deficiency in the medical literature.

Echocardiographic findings in endomyocardial fibrosis

An 18-month-old infant diagnosed as having endomyocardial fibrosis by echocardiography is presented. Most patients with endomyocardial fibrosis reported in the literature are either older children or adults. To our knowledge, our patient was the youngest ever to have been reported. Echocardiographic studies showed obliteration of the left ventricular apex and increased echo reflectance at the left ventricular endocardium and subendocardium. The left atrium and right ventricle were significantly enlarged. Doppler echocardiography showed minimal mitral, but significant tricuspid regurgitation. In regard to the contribution of echocardiography in the diagnosis, we recommend this method for suspected cases. Contrary to the other patients reported, there was no thickening of the atrioventricular valves. Mitral valve insufficiency was related to the restriction of the ventricular filling rather than to valve involvement occurring with the disease.

Two-dimensional echocardiographic findings in postoperative aortic suture line endarteritis

Infections occurring after aortic valve surgery, whether valvuloplasty or replacement, commonly affect the valve itself. However infection of the aortic suture line alone is extremely rare. Such cases with endarteritis can be diagnosed at autopsy or by angiocardiography. In this report a patient with a vegetation at the aortic suture line which was diagnosed by echocardiography is presented. By two-dimensional echocardiography, a very mobile and echo-dense mass protruding from the ascending aorta was observed on the recordings through the suprasternal notch. This diagnosis was surgically confirmed and the patient was treated.

Endomyocardial biopsy in children. Usefulness in various myocardial disorders

Endomyocardial biopsy studies in adults have demonstrated the usefulness of this method. It is possible that studies will be more productive in determining the etiology and clinical status in patients with clinically diagnosed myocardial diseases. A prospective study conducted over 16 months included 17 children, aged 14 months to 18 years, with the diagnosis of dilated, restrictive cardiomyopathy and myocarditis. In 16 patients right, and in 1 patient left heart endomyocardial biopsies were performed. The specimens were evaluated by light and electron microscopy. There were no serious complications after the procedure. In 1 of 17 children histology showed no myocardial tissue. Electron microscopy evaluations were currently available in 9 patients. Endomyocardial biopsy findings were found to be diagnostic in 41.2%, helpful in 29.4% and of no help in 29.4% of patients. In conclusion, endomyocardial biopsy technique is highly sensitive in children with myocardial disorders. In future it will be the major diagnostic tool for invasive but safe detection of myocardial disease.

Peripheral vein contrast echocardiography in atrial septal defect

This study was carried out on 233 children suspected clinically of having atrial septal defect with the aim of investigating the diagnostic capability of peripheral venous contrast echocardiography. The transfer of contrast material from the right atrium into the left atrium was evaluated as "positive contrast", while noncontrast blood, passing from the left atrium into the right atrium was termed "negative contrast". Positive contrasts were quantitated in four grades. A significant negative contrast effect was graded 3- or 4-. Three positive, 4+ and/or 3-, 4- contrast effects were considered definite evidence of an atrial septal defect. Among the cases with the above findings 92 underwent surgical closure of atrial septal defect. The procedure was successful in all patients operated; the size of the defect was large. This result demonstrates that the method applied is a safe and reliable one. However, in a group of cases without the above echocardiographic findings the presence of an atrial septal defect was detected by cardiac catheterization and angiocardiography. Therefore, we can conclude that the method applied is not a sensitive, but a specific one, for definite detection of atrial septal defect.