[Outcome at two years corrected age of a cohort of very low birth weight infants from hospitals within the neonatal SEN1500 network]

OBJECTIVE

To describe growth and neurodevelopmental status of 4,944 children who completed a follow-up at two years of corrected age out of the 10,456 newborns with weight ≤1500g born between the years 2002-2007 and discharged from hospitals within the network SEN1500. A total of 522 newborns were excluded as they had some type of malformation. The total number of children assessed represents the 49.76% of children discharged alive and without malformations.

METHODS

A retrospective review was conducted using prospectively collected data in the SEN1500 database. We compared growth data at two years of corrected age according to birth weight and sex. Motor impairment, incidence of cerebral palsy, visual and hearing disabilities, and abnormal neurodevelopment for gestational age were analysed between groups. We studied the associations between cerebral palsy (CP) and perinatal factors.

RESULTS

At 2 years of age 44.2% of children had a weight <2 SD for corrected age. Children with birth weight ≤1000g showed worse outcomes in growth. Some type of motor impairment was observed in 6.96% of the infants, and 4.56% of them were diagnosed with CP. The incidence was higher among males with birth weight ≤1000g. There was an incidence of 5.21% of visual disability, with 0.5% of children being blind in one or both eyes. Cerebral palsy was associated with retinopathy of prematurity, severe intraventricular haemorrhage, and periventricular leukomalacia, in particular cystic periventricular leukomalacia.

Host and environmental factors influencing respiratory secretion of pro-wheezing biomarkers in preterm children

Cytokines are actively secreted by the respiratory mucosa of preterm children and participate in the pathogenesis of wheezing. This study aimed to identify the factors that could potentially influence respiratory secretion of cytokines in these children. A nasopharyngeal aspirate (NPA) was collected from 77 preterm children 1 yr after birth. NPAs from 14 healthy, 1-yr-old term children were collected in parallel. 27 cytokines were measured in the NPAs using a multiplex assay. Multivariate stepwise regression analysis with Bonferroni correction evidenced that the variable [daycare attendance] was associated with higher levels of [monocyte chemoattractant protein-1 (MCP-1), IL-6, vascular endothelial growth factor (VEGF), IL-1β, IL-10, tumor necrosis factor (TNF)-α]; [male sex] with higher levels of (MCP-1, VEGF, and IL-1β); [smokers at home] was associated with higher levels of MCP-1 (p < 0.0013). In turn, [prophylaxis with palivizumab] was associated with lower levels of (IL-6, IL-7) (p < 0.0013). All these mediators participate in the pathogenesis of asthma and recurrent wheezing. Preterm children secreted higher levels of chemokines (interferon-gamma inducible protein-10, macrophage inflammatory protein-1α, Eotaxin, MCP-1), growth factors (platelet-derived growth factor-bb, VEGF, fibroblast growth factor-basic, granulocyte macrophage colony-stimulating factor), Th1 (IL12, interferon-γ), Th2 (IL-9, IL-13), Th17 (IL-6, IL-17) cytokines, and immunomodulatory mediators (IL1RA and granulocyte colony-stimulating factor) than term children. In conclusion, we have identified for the first time a group of individual and environmental factors influencing respiratory secretion of cytokines in preterm children at the long term after birth. To know these factors could help to prevent the instauration of conditions linked to the appearance of chronic respiratory diseases such as wheezing or asthma.

ECG spectral and morphological parameters reviewed and updated to detect adult and paediatric life-threatening arrhythmia

Since the International Liaison Committee on Resuscitation approved the use of automated external defibrillators (AEDs) in children, efforts have been made to adapt AED algorithms designed for adult patients to detect paediatric ventricular arrhythmias accurately. In this study, we assess the performance of two spectral (A(2) and VFleak) and two morphological parameters (TCI and CM) for the detection of lethal ventricular arrhythmias using an American Heart Association (AHA) compliant database that includes adult and paediatric arrhythmias. Our objective was to evaluate how those parameters can be optimally adjusted to discriminate shockable from nonshockable rhythms in adult and paediatric patients. A total of 1473 records were analysed: 751 from 387 paediatric patients (<or=16 years of age) and 722 records from 381 adult patients. The spectral parameters showed no significant differences (p > 0.01) between the adult and paediatric patients for the shockable records; the differences for nonshockable records however were significant. Still, these parameters maintained the discrimination power when paediatric rhythms were included. A single threshold could be adjusted to obtain sensitivities and specificities above the AHA goals for the complete database. The sensitivities for ventricular fibrillation (VF) and ventricular tachycardia (VT) were 91.1% and 96.6% for VFleak, and 90.3% and 99.3% for A(2). The specificities for normal sinus rhythm (NSR) and other nonshockable rhythms were 99.5% and 96.3% for VFleak, and 99.0% and 97.7% for A(2). On the other hand, the morphological parameters showed significant differences between the adult and paediatric patients, particularly for the nonshockable records, because of the faster heart rates of the paediatric rhythms. Their performance clearly degraded with paediatric rhythms. Using a single threshold, the sensitivities and specificities were below the AHA goals, particularly VT sensitivity (60.4% for TCI and 65.8% for CM) and the specificity for other nonshockable rhythms (51.7% for TCI and 34.5% for CM). The specificities, particularly for the adult case, improve when the thresholds are independently adjusted for each adult and paediatric database.

[Acute myocardial infarction complicating radiofrequency catheter ablation in a girl]

Paroxysmal supraventricular tachycardia is the most common tachyarrhythmia in childhood and adolescence. The current treatment of choice for managing and preventing frequent recurrences is radiofrequency catheter ablation, which provides a definitive solution in most cases. This technique is very effective but not devoid of potential complications, particularly in children and adolescents. We report the case of a 3-year-old girl who suffered acute myocardial infarction after occlusion of the right coronary artery during this procedure. We describe intraoperative and postoperative management. Progress was good and the patient was discharged 14 days after ablation.

[Non-pulsatile aneurysm of the superficial temporal artery: a report of a case]

Aneurysms of the superficial temporal artery are an uncommon cause for preauricular or parotid masses. Trauma is the most frequent etiology for a pseudoaneurysm and atheromatosis for the true aneurysm. The diagnosis is clinical due to their vascular signs (pulsatile mass, thrill...), these signs care not present when the aneurysmnas thrombosed, being this an unusual event that will make difficult a proper diagnosis. Radiological investigations are needed and helpful under these circumstances. Surgery is curative and recommended, being the excision after proximal and distal ligation of the artery the most accepted procedure. Aneurysms of the superficial temporal artery are rarely reported in the literature. We report a case that showed up as a non-pulsatile preauricular mass to highlight this unusual condition.

Discrete subaortic stenosis in adults: increased prevalence and slow rate of progression of the obstruction and aortic regurgitation

OBJECTIVES

We sought to determine the prevalence and rate of progression of left ventricular outflow tract obstruction (LVOTO) and aortic regurgitation (AR) in adults with discrete subaortic stenosis (DSS).

BACKGROUND

Discrete subaortic stenosis is an uncommon form of LVOTO, with rapid hemodynamic progression in children, but the prevalence and rate of progression in adults have not been studied so far.

METHODS

The prevalence of DSS was determined in 2,057 consecutive adults diagnosed with congenital heart disease (CHD). The relationship between LVOTO on Doppler echocardiography and patient age was analyzed. Sequential changes in LVOTO and AR were determined for patients with two or more Doppler echocardiograms obtained with at least a two-year interval.

RESULTS

A total of 134 adults (mean age 31 +/- 17 years) were diagnosed with DSS. The prevalence was 6.5% for all adults with CHD. Sixty patients (44%) had other associated CHD. The mean age of 29 patients who had undergone an operation for DSS during their adult life (56 +/- 15 years) was significantly higher than that of 64 patients (27 +/- 13 years) who had not required a surgical intervention (p < 0.0001). A significant relationship between LVOTO and patient age (r = 0.61, p < 0.0001) was found: 21 +/- 16 mm Hg in patients <25 years old, 51 +/- 47 mm Hg for those between 25 and 50 years old, and 78 +/- 36 mm Hg for those >50 years old. The LVOTO increased from 39.2 +/- 28 to 46.8 +/- 34 mm Hg (p = 0.01) during a mean follow-up of 4.8 +/- 1.8 years in 25 patients. The slope of the change in LVOTO was 2.25 +/- 4.7 mm Hg per year of follow-up. Aortic regurgitation was detected by color Doppler imaging in 109 patients (81%), but it was hemodynamically significant in <20%. An increase in the mean degree of AR over time was not significant (baseline: 1.3 +/- 0.8; follow-up: 1.5 +/- 0.9; p = 0.096).

CONCLUSIONS

The prevalence of DSS is increasing in adults due to the greater number of repaired CHDs that develop into evolutive DSS. In contrast to infants and children, adults with DSS show a slow rate of LVOTO progression. Aortic regurgitation is a common but usually mild and nonprogressive consequence. The current indications for surgical intervention should be revised.

[Stent dilatation of pulmonary artery stenosis in the adult patient with congenital heart disease]

Stents have been previously used to resolve stenoses of branch pulmonary arteries in children. We report 3 patients, with mean age of 22.7 +/- 4.7 years and pulmonary artery stenosis after palliative surgery in whom we implanted seven stents in four procedures. Six P308 Palmaz, overlapped two by two, were implanted by venous femoral approach in two patients, receiving four in the first case and the other two in the third case. In the second case, a NIR type stent was implanted through femoral artery in the right pulmonary artery. Stenosis diameter enlarged from 5.3 +/- 2.3 to 14.4 +/- 4.2 mm and the pressure gradient through stenosis fell from 40.6 +/- 15.3 to 6. 5 +/- 5 mmHg. All stents are well deployed and there are two patients waiting for total correction (previously not feasible) during a follow-up of 30.6 +/- 6.1 months.

Unusual longevity without surgical intervention in complete transposition of the great arteries

A case of unusual longevity to the age of 58 years is reported for a female patient with complete transposition of the great arteries. The association with a wide atrial septal defect with intact interventricular septum may have contributed to the long survival without surgery. Factors determining intercirculatory mixing and systemic oxygen saturation may be the high pulmonary flow, the location of the anatomic communication, sufficient hemoglobin concentration to allow an adequate level of systemic resistance and recirculated systemic flow, and the belated development of pulmonary vascular disease.

[Stent implantation in systemic venous baffle obstruction after Mustard-type operation repair in an adult]

Late systemic venous baffle obstruction after Mustard repair for complete transposition of the great arteries is a recognized complication. Balloon-expandable intravascular stents have previously been used to relieve systemic baffle narrowing in children. We report a successful stent implantation to relieve symptomatic superior vena cava obstruction and baffle dehiscence after Mustard repair in an adult patient. She had been turned down for surgery due to right ventricular dysfunction. Eighteen months after the procedure, she remains symptomless.

Radiofrequency catheter ablation of accessory pathways in infants

OBJECTIVE

To evaluate the indications, results and complications of radiofrequency catheter ablation in small infants with supraventricular tachycardia due to an accessory atrioventricular pathway.

METHODS

Five infants less than 9 months old underwent radiofrequency catheter ablation of accessory pathways. Ablation was done for medically refractory tachyarrhythmia associated with aborted sudden death in two patients, left ventricular dysfunction in one, failure of antiarrhythmic drugs in one, and planned cardiac surgery in one. All five patients underwent a single successful procedure. Three left free wall pathways were ablated by transseptal approach, a right posteroseptal pathway was ablated from the inferior vena cava, and a left posteroseptal pathway was approached from the inferior vena cava into the coronary sinus. A deflectable 5F bipolar electrode catheter with a 3 mm tip was used.

RESULTS

A sudden increment in impedance indicative of coagulum formation was observed in two procedures. One patient developed a transient ischaemic complication after ablation of a left lateral accessory pathway by transseptal approach. This patient had mild pericardial effusion after the procedure. Moderate pericardial effusion was also noted in another patient. After a mean follow up of 18.4 months all patients are symptom free without treatment.

CONCLUSIONS

Radiofrequency catheter ablation can be performed successfully in infants. Temperature monitoring in 5F ablation catheters would be desirable to prevent the development of coagulum. Echocardiography must be performed after the ablation procedure to investigate pericardial effusion.

Reversibility of tachycardia-induced cardiomyopathy after radiofrequency ablation of incessant supraventricular tachycardia in infants

Tachycardia-induced cardiomyopathy developed in a 3 month old infant with permanent junctional reciprocating tachycardia, which was incessant despite medical treatment. The patient underwent transcatheter radiofrequency ablation. There were no complications and 8 months after the procedure the patient was symptom free without medication.

Steatocrit: a reliable semiquantitative method for detection of steatorrhea

Steatocrit is a semiquantitative method for determination of fat content in fecal samples. Previous studies, mostly performed in children, reported controversial results. The aim of our study was to compare the determination of fat content in 148 fecal samples by two methods: the conventional van de Kamer and the steatocrit. Seventy-seven fecal samples had steatorrhea (> 7 g/day). The upper normal limit for the steatocrit (determined by the mean +/- 2 SD of samples without steatorrhea) was 2.1%. The steatocrit showed a sensitivity of 87%, specificity of 97%, and positive and negative predictive values of 97 and 87%, respectively. When fecal fat excretion > 20 g/day was evaluated, sensitivity increased to 98%. A significant linear correlation was found between steatocrit and the quantitative chemical method (r = 0.80; p < 0.0001). In conclusion, the steatocrit is satisfactory in the discrimination of patients with and without fat malabsorption. It is a simple, rapid, inexpensive, and reliable semiquantitative test that can be used when other methods are impractical.

Reaction of 6-hydroxytetrahydro-beta-carboline-3-carboxylic acids with isocyanates and isothiocyanates

The reaction of (-)-(3,S)-6-hydroxy-1,2,3,4-tetrahydro-beta-carboline-3-carboxylic acid (3a) with isocyanates and isothiocyanates gave the (+/-)-beta-carboline-hydantoin (4a-d) and -thiohydantoin systems (5a-d). The treatment of (-)-(1S,3S)-6-hydroxy-1-methyl-1,2,3,4-tetrahydro-beta-carboline-3-ca rbo xylic acid (3b) with isocyanates yielded the (+/-)-cis diastereomer of the beta-carboline-hydantoin rings (4e-h). However, the reaction of 3b with isothiocyanates provided the corresponding trans isomer (5e-h). These results have been confirmed by 13C-NMR data and nuclear Overhauser effect (NOE) experiments. The new compounds were tested for in vitro binding affinity to the central-type benzodiazepine receptors.

[Relationship between maximum arterial pressure response to exercise and left ventricular hypertrophy in normotensive subjects]

INTRODUCTION AND OBJECTIVES

To determine whether normotensive persons with increases of systolic blood pressure with exercise have left ventricular hypertrophy and/or diastolic disfunction.

METHODS

A cross-sectional study, using echocardiography as a measurement of left ventricular hypertrophy and diastolic disfunction, was made among healthy population: 53 men, voluntary office workers from a firm and conscript army recruits, aged between 19 and 51 (mean 28, SD = 10.3) who were subjected to the exercise test and the echocardiography.

RESULTS

Twelve people (22.6%) with left ventricular mass index superior to 134 g/m2; and five (9.4%) with a systolic response during exercise higher than 210 mm of Hg. The multiple linear regression showed an association between maximum systolic blood pressure with exercise and the left ventricular mass index in the entire group of subjects (R2 = 18.4%: p < 0.01), but a modification effect with age was detected: no association was found (R2 = 2.8%; p = 0.37) among people under 25 (n = 30), but one was found among the older subjects (R2 = 28.8%; p < 0.01). Diastolic disfunction was associated with age, baseline heart rate and resting diastolic blood pressure (R2 = 64.3%; p < 0.01).

CONCLUSIONS

In normotensive subjects, the finding of an exaggerated blood pressure response to exercise could be related to left ventricular hypertrophy.

[Transposition of the great arteries. A follow-up of patients operated on with atrial correction]

The late results of 146 patients with transposition of the great arteries (simple: 119, complex: 27) surviving to physiological correction (Mustard: 33, Senning: 113) are analyzed. The mean age at operation was 27 months (1-120), and the mean follow-up was 78 months (6-187). The mean P wave voltage significantly decreased (from 0.3 mV preoperatively to 0.16 mV postoperatively). Frontal mean P wave axis varied from 63.9 degrees to 71.3 degrees. Mean heart rate were significantly lower than those for age-matched normal children. Previous atrioseptectomy had been performed in 36 patients and five of them had arrhythmias before operation. 78 (55%) out of the remaining 141 showed arrhythmias in the surface ECG: sinus node disfunction in 51, tachyarrhythmias in eight, atrioventricular block in eight and several association of arrhythmias in 11. Actuarial survival free of arrhythmias is 81% at the first year, 49% at 5 years and 22% at 15 years. The incidence of arrhythmias in the group of 92 patients with Holter monitoring was higher, with 73 cases having arrhythmias (79%): sinus node disfunction in 47, tachyarrhythmias in ten, atrioventricular block in four and associated in 12. Survival free of arrhythmias by both methods (ECG and Holter) shows a 78% at the first year, 28% at 5 years and 5.6% at 15 years. No significant correlation was found between the incidence of arrhythmias and the type of TGA (simple or complex) or the surgical technique (Mustard or Senning). Permanent pacemakers were implanted in seven to a mean follow-up of 7 years. Five patients were reoperated to a mean follow-up of 46 months. There were 7 late deaths to a mean follow-up of 13 months, four of them being sudden. The actuarial survival rate for the whole group was 93.5% at 15 years. No significant correlation was found between the late mortality and the type of TGA or operation. There was also no correlation with the incidence of arrhythmias. Residual lesions were found in 46 patients, hemodynamically significant in ten. Functional status was class I (NYHA) in 123, and class II in 16. There was correlation between the functional class and the residual lesions.

Aberrant left pulmonary artery with tracheal stenosis without vascular sling

We report a case of abnormal origin of the left pulmonary artery from the right pulmonary artery, associated with tracheal stenosis but with no vascular sling. This is the first such case, to our knowledge, without vascular sling.

Cardiac rhabdomyoma presenting as fetal hydrops

Fetal hydrops and possible congenital heart disease with atrioventricular block was diagnosed one day before birth in a male infant of 35 weeks' gestation. Echocardiography and angiocardiography soon after birth revealed a cardiac tumor. The child died three days after birth. Necropsy showed tuberous sclerosis involving the heart (type-I rhabdomyoma), kidneys, retina, and central nervous system.

[Right cervical aortic arch: report of 2 cases, one associated with aortic coarctation]

Cervical aortic arch is a rare congenital vascular anomaly. Usually it appears as an asymptomatic pulsatile cervical mass, but symptoms of tracheal and esophageal compression may be present in 25% of the patients. About 40% of cases are associated with vascular or heart abnormalities. Angiography provides definitive diagnosis. Authors report two patients with right cervical aortic arch, one of them associated with aortic coarctation, and review 52 published cases.