Congenital heart defects in CTNNB1 syndrome: Raising clinical awareness

CTNNB1 [OMIM *116806] encodes β-catenin, an integral part of the cadherin/catenin complex, which functions as effector of Wnt signaling. CTNNB1 is highly expressed in brain as well as in other tissues, including heart. Heterozygous CTNNB1 pathogenic variations are associated with a neurodevelopmental disorder characterized by spastic diplegia and visual defects (NEDSDV) [OMIM #615075], featuring psychomotor delay, intellectual disability, behavioral disturbances, movement disorders, visual defects and subtle facial and somatic features. We report on a new series of 19 NEDSDV patients (mean age 10.3 years), nine of whom bearing novel CTNNB1 variants. Notably, five patients showed congenital heart anomalies including absent pulmonary valve with intact ventricular septum, atrioventricular canal with hypoplastic aortic arch, tetralogy of Fallot, and mitral valve prolapse. We focused on the cardiac phenotype characterizing such cases and reviewed the congenital heart defects in previously reported NEDSDV patients. While congenital heart defects had occasionally been reported so far, the present findings configure a higher rate of cardiac anomalies, suggesting dedicated heart examination to NEDSDV clinical management.

The heart in RASopathies

The cardiovascular phenotype associated with RASopathies has expanded far beyond the original descriptions of pulmonary valve stenosis by Dr Jaqueline Noonan in 1968 and hypertrophic cardiomyopathy by Hirsch et al. in 1975. Because of the common underlying RAS/MAPK pathway dysregulation, RASopathy syndromes usually present with a typical spectrum of overlapping cardiovascular anomalies, although less common cardiac defects can occur. The identification of the causative genetic variants has enabled the recognition of specific correlations between genotype and cardiac phenotype. Characterization and understanding of genotype-phenotype associations is not only important for counseling a family of an infant with a new diagnosis of a RASopathy condition but is also critical for their clinical prognosis with respect to cardiac disease, neurodevelopment and other organ system involvement over the lifetime of the patient. This review will focus on the cardiac manifestations of the most common RASopathy syndromes, the relationship between cardiac defects and causal genetic variation, the contribution of cardiovascular abnormalities to morbidity and mortality and the most relevant follow-up issues for patients affected by RAS/MAPK pathway diseases, with respect to cardiac clinical outcomes and management, in children and in the adult population.

Brugada pattern revealed during SARS-COV-2-related multi-systemic inflammatory syndrome in a 6-year-old child

Rhythm abnormalities are rare during COVID-19-related multisystem inflammatory syndrome in children (MIS-C). We are reporting the detection of type I Brugada pattern in a 6-year-old child with MIS-C. Following the start of treatment (systemic steroids and immunoglobulins), a gradual evolution of cardiac rhythm up to normalisation was observed, concomitantly with a progressive reduction of inflammatory markers.

Role of Troponin Determination to Diagnose Chest Pain in the Pediatric Emergency Department

OBJECTIVES

Chest pain is a common cause to admission to the pediatric emergency department and often leads to an extensive cardiac evaluation. The objective of this study was to evaluate the usefulness of the troponin (TN) plasma level determination in the initial phase of the differential diagnosis of chest pain in children.

METHODS

This is a retrospective observational study on 107 patients, aged 0 to 19 years, admitted for chest pain to the pediatric emergency department of our institution. Demographics, clinical data, and patient outcomes were analyzed. Troponin values of >0.03 ng/mL but <0.1 ng/mL were considered suspected for cardiac pathology, whereas levels of >0.1 ng/mL were indicative of cardiac pathology. In these latter patients, an echocardiographic examination was also performed.

RESULTS

Only 99 patients were evaluated with electrocardiogram (ECG). In 91 of 99 patients of our series, both TN determination and ECG recording were performed. Troponin was higher than the cutoff value (0.03 ng/mL) in 9 patients (9.1%). Only 2 of the 9 patients who presented high TN values showed a nonpathological ECG, whereas 16 (17.5%) of 91 patients in whom both ECG and TN determination were performed had ECG abnormalities without a simultaneous elevation of TN. Of the 26 patients who had medical history and suggestive targets of cardiac pathology, only in 6 (23.1%) of them the diagnosis was confirmed. The final diagnosis of the 99 patients was idiopathic chest pain in 45.4% of cases.

CONCLUSIONS

Even with the low cost and the relatively easiness for the plasma level determination, TN should be measured only in children with chest pain associated to familiar history suggestive of cardiovascular disease and/or clinical symptoms and/or ECG alterations.

Complications associated with myocardial bridging in four children without underlying cardiac disease: a case series

BACKGROUND

Myocardial bridging is largely considered to be a benign, symptomless congenital anomaly of the coronary arteries in which the intramyocardial coronary course is partially 'tunnelled' and leads to vessel compression during ventricular systole. There are few data regarding children.

OBJECTIVE

To report on myocardial bridging observed in children seeking medical help in the paediatric emergency room.

CASE PRESENTATION

A series of four children aged 6-13 years with symptomatic myocardial bridging but no other underlying cardiac abnormalities is reported. They were admitted to the paediatric emergency department during 2013-2016, three with chest pain after physical activity and one with septic shock.

RESULTS

Heart computed tomography scan in the first three demonstrated myocardial bridging of the left anterior descendent coronary artery's branches; their 2-year follow-up was uneventful. The fourth patient presented with ventricular fibrillation 24 hours after admission and at autopsy there was an intramyocardial tract 4 cm long on the left anterior descendent coronary artery.

CONCLUSIONS

This case series demonstrates that myocardial bridging can be symptomatic in children with no underlying cardiac disorders and should be included in the differential diagnosis of exertional chest pain and/or arrhythmias.Abbreviations: CRP, C-reactive protein; CT, computed tomography; D1, diagonal 1 artery; ECG, electrocardiogram; ED, emergency department; KD, Kawasaki disease; LAD, left anterior descending coronary artery; MB, myocardial bridging; RI, ramus intermedius artery; TN, troponin.

Genotype-cardiac phenotype correlations in a large single-center cohort of patients affected by RASopathies: Clinical implications and literature review

Congenital heart disease (CHD) and hypertrophic cardiomyopathy (HCM) are common features in patients affected by RASopathies. The aim of this study was to assess genotype- phenotype correlations, focusing on the cardiac features and outcomes of interventions for cardiac conditions, in a single-center cohort of 116 patients with molecularly confirmed diagnosis of RASopathy, and compare these findings with previously published data. All enrolled patients underwent a comprehensive echocardiographic examination. Relevant information was also retrospectively collected through the analysis of clinical records. As expected, significant associations were found between PTPN11 mutations and pulmonary stenosis (both valvular and supravalvular) and pulmonary valve dysplasia, and between SOS1 mutations and valvular defects. Similarly, HRAS mutations were significantly associated with HCM. Potential associations between less prevalent mutations and cardiac defects were also observed, including RIT1 mutations and HCM, SOS2 mutations and septal defects, and SHOC2 mutations and septal and valve abnormalities. Patients with PTPN11 mutations were the most likely to require both a primary treatment (transcatheter or surgical) and surgical reintervention. Other cardiac anomalies less reported until recently in this population, such as isolated functional and structural mitral valve diseases, as well as a sigmoid-shaped interventricular septum in the absence of HCM, were also reported. In conclusion, our study confirms previous data but also provides new insights on cardiac involvement in RASopathies. Further research concerning genotype/phenotype associations in RASopathies could lead to a more rational approach to surgery and the consideration of drug therapy in patients at higher risk due to age, severity, anatomy, and comorbidities.

Neonatal Life-Threatening Nonoliguric Hyperkalemia Under Therapeutic Hypothermia

To illustrate our experience with two cases of neonatal life-threatening hyperkalemia during therapeutic hypothermia (TH) despite a normal acid-base status, urine output, and preserved renal function. Clinical cases are presented from Pediatric Intensive Care Unit (PICU) admission to the onset of the hyperkalemia, with related complications and after resolution. Similar cases were not retrieved from a critical review of pertinent literature. Severe hyperkalemia pathophysiology and risk factors have been debated. Two full-term adequate for weight female neonates were admitted to PICU because of perinatal asphyxia who underwent TH. Prenatal history was completely uneventful, nor hereditary genetic conditions were reported; moreover, long-term follow-up ruled out any metabolic or renal disease. Despite an accurate evaluation of previous clinical series and literature on TH and perinatal asphyxia, these hyperkalemic episodes remain unexplained. The hypoxic-ischemic insult may affect multiple organs, mainly central nervous system, heart, lung, and kidneys; acute muscle breakdown and consequent rising of myoglobin may also have a precipitating role in acute kidney failure (AKF) and hyperkalemia. Electrolyte imbalance is a possible finding as a consequence of combined cell injury and AKF. In contrast, an isolated severe hyperkalemia is exceedingly rare in nonoliguric neonates.

Clinical applications of Lung Ultrasound in children in Pediatric Emergency Setting: a lesson from a child with severe heart disease

Background and aim:

Rheumatic Heart Disease (RHD) often evolves in congestive heart failure with development of pulmonary edema after a asymptomatic, latent phase. In the last years, Lung Ultrasound (LUS) has gained a primary role in the diagnosis and management of pleuropulmonary disorders, also in pediatric practice, and in the diagnosis and follow-up of pulmonary edema through qualitative analysis of ultrasound B-lines. Aim of this case report is to keep high clinicians’ attention to the diagnosis of Rheumatic Heart Disease also in high-income countries and to deepen the role and importance of lung ultrasound in clinical practice, in diagnosis and follow-up of pediatric lung diseases, especially in emergency settings as happened in our case.

Methods:

We present the case of a 14-year-old Italian boy from a medium-low socio-economic and cultural class Italian family, who was diagnosed with severe and advanced stage RHD, which had remained undiagnosed until then.

Results and Conclusions:

In the diagnostic process of our case, LUS played a fundamental role because it quickly directed us, contextually to the clinical and anamnestic evaluation, towards the right diagnosis, in a Pediatric Emergency Department. In clinical practice, the only LUS findings and the only qualitative analysis of the B-lines, have note made clinicians able to make a clear characterization yet. Thus, the study of cardiovascular function, laboratory parameters, anamnestic and clinical data continue to be useful tools in order to assist LUS in the diagnostic processes of lung diseases, as in our case. (www.actabiomedica.it)

Smith-Magenis syndrome: Report of morphological and new functional cardiac findings with review of the literature

Smith-Magenis syndrome (SMS) is a genetic disorder characterized by multiple congenital anomalies, sleep disturbance, behavioral impairment, and intellectual disability. Its genetic cause has been defined as an alteration in the Retinoic Acid-Induced 1 gene. Cardiac anomalies have been reported since the first description of this condition in patients with 17p11.2 deletion. Variable cardiac defects, including ventricular septal defects, atrial septal defects, tricuspid stenosis, mitral stenosis, tricuspid and mitral regurgitation, aortic stenosis, pulmonary stenosis, mitral valve prolapse, tetralogy of Fallot, and total anomalous pulmonary venous connection, have been anecdotally reported and systematic case series are still lacking. Herein, we define the spectrum of the cardiac phenotype and describe for the first time the cardiac function in a large cohort of pediatric patients with SMS. Revision of the literature and correlations between genotype and cardiac phenotype was performed.

Resolution of Giant Coronary Aneurisms in a Child With Refractory Kawasaki Disease Treated With Anakinra

Kawasaki disease (KD) is an acute, febrile illness of unknown etiology that mainly affects children under 5 years of age. intravenous immunoglobulin (IVIG), the standard treatment, has reduced coronary involvement to <5%. Patients who do not improve after an initial IVIG have a higher risk of developing coronary arteries aneurysms, and its optimal treatment remains controversial. We present a case of IVIG, steroids, and infliximab-resistant KD in a 9-month-old child, which developed giant aneurysms and was successfully treated with anakinra, a recombinant antagonist of the IL-1 receptor. In our case, the introduction of IL-1 receptor antagonist therapy seems to have blocked the disease from both a clinical and a laboratory point of view. We also noted a very rapid regression of coronary aneurysms passed from giant aneurysms to small ones, or, as in the case of the anterior descending artery, the complete disappearance of the aneurysm formation. We think that our case adds more evidences to the potential role of IL-1RA as therapy in some selected cases of refractory KD, in particular with severe involvement of coronary arteries, although new efficacy trials are needed to better understand the role of Anakinra in these patients.

Outcome of Neonates with Vein of Galen Malformation Presenting with Severe Heart Failure: A Case Series

BACKGROUND

Neonatal presentation of vein of Galen aneurysmal malformations (VGAMs) complicated by cardiac failure and pulmonary hypertension is frequently associated with a poor prognosis. Interventional neuroradiology with embolization can offer a chance for survival, although neurological damage can represent a limitation.

OBJECTIVE

This article determines if aggressive intensive care and drug management of cardiac failure before urgent embolization can influence morbidity and mortality.

PATIENTS AND METHODS

Twelve infants (7 boys, 5 girls) were diagnosed with symptomatic vein of Galen malformations in the neonatal period during the period 2000 to 2014. Due to high output cardiac failure, endovascular treatment was attempted as soon as stabilization was achieved.

RESULTS

Endovascular procedures successfully reverted cardiac failure in 5 patients who survived without significant neurological damage, while in 7 patients the causes of death were refractory cardiac failure, multiorgan failure, and severe brain damage. Bidimensional echocardiography assessment was performed at presentation and after early embolization procedures.

CONCLUSION

Aggressive intensive care approach to heart failure and pulmonary hypertension leading to early neurointervention results in good survival rates with low morbidity even in cases of high-risk neonatal VGAM. Combined hemodynamic treatment can improve outcome in neonates with cardiac failure secondary to VGAM, although there is the risk of precipitating systemic hypoperfusion and renal failure. A moderate prematurity may not prevent both interventional approach and good outcome.

Autoimmunity and autoinflammation as the yin and yang of idiopathic recurrent acute pericarditis

Autoimmunity and autoinflammation are generally considered as mutually exclusive mechanisms of diseases but may concur to specific syndromes. Idiopathic recurrent acute pericarditis (IRAP) is defined as the recurrence of pericardial symptoms at any point following the prior cessation of acute pericarditis, and the latency is generally 6 weeks. Manifestations of pericarditis such as pericardial friction rub, electrocardiographic changes, and pericardial effusion are less frequent in the subsequent episodes compared to the index attack, and in some cases the only clinical sign is represented by a suggestive chest pain. Several autoimmune diseases may manifest with pericarditis which is often related to viral infections, while postviral pericarditis may in turn display a nonspecific autoimmune background. Similarly, autoinflammatory syndromes such as familial Mediterranean fever and tumor necrosis factor receptor-associated periodic syndrome are characterized by self-limiting pericardial symptoms. Corticosteroids are generally effective, thus supporting the autoimmune nature of IRAP, but dramatic results are obtained with interleukin-1 blocking agents in corticosteroid-dependent cases, pointing to a pathogenic role for the inflammasome. Based on these observations, we submit that IRAP represents a paradigmatic example of the putative coexistence of autoimmunity and autoinflammation: the main aim of this review is to critically discuss the hypothesis as well as the current understanding of this enigmatic clinical condition.

Kawasaki syndrome and concurrent Coxsackie virus B3 infection

We describe two previously healthy children who were hospitalized in the same period in different departments of our University with clinical signs of Kawasaki syndrome, which were treated with intravenous immunoglobulins and acetylsalicylic acid: in both cases, Coxsackie virus infection was concurrently demonstrated by enzyme-linked immunosorbent assay, and complement fixation test identified antibodies to serotype B3. In the acute phase, both patients presented hyperechogenic coronary arteries, but no cardiologic sequels in the mid term. The etiological relationship between Kawasaki syndrome and Coxsackie viruses is only hypothetical; however, the eventual identification of ad hoc environmental triggers is advisable in front of children with Kawasaki syndrome, with the aim of optimizing epidemiological surveillance and understanding the intimate biological events of this condition.

Nebulized iloprost and noninvasive respiratory support for impending hypoxaemic respiratory failure in formerly preterm infants: a case series

OBJECTIVE

To describe a series of ex-preterm infants admitted to pediatric intensive care unit due to impending hypoxaemic respiratory failure complicated by pulmonary hypertension (PH) who were treated electively combining noninvasive ventilation (NIV) and nebulized iloprost (nebILO).

DESIGN

Open uncontrolled observational study.

SETTING

Pediatric Intensive Care Unit, University Hospital.

PATIENTS

Ten formerly preterm infants with impending hypoxaemic respiratory failure and PH, of whom eight had moderate to severe bronchopulmonary dysplasia.

MEASUREMENTS AND MAIN RESULTS

Median age and body weight were 6.0 (2.75-9.50) months and 4.85 (3.32-7.07) kg, respectively. We observed a significant early oxygenation improvement in terms of PaO(2) /FiO(2) increase (P = 0.001) and respiratory rate reduction (P = 0.01). Hemodynamic also improved, as shown by heart rate (P = 0.002) and pulmonary arterial pressure systolic/systolic systemic pressure (PAPs/SSP) ratio reduction (P = 0.0137). NebILO was successfully weaned in positive response cases: 4 infants were discharged on oral sildenafil. Three patients failed noninvasive modality and needed invasive mechanical ventilation; hypoxic-hypercarbic patients were most likely to fail noninvasive approach. Only one patient requiring invasive ventilation died and surviving babies had a satisfactory 1-month post-discharge follow-up. CONCLUSIONS.: The noninvasive approach combining NIV and nebILO for ex-preterm babies with impending respiratory failure and PH resulted to be feasible and quickly achieved significant oxygenation and hemodynamic improvements.

Levosimendan in two neonates with ischemic heart failure and pulmonary hypertension

We report the successful and safe use of levosimendan, a new calcium-sensitizing agent with positive inotropic and vasodilatory action, in 2 critically ill term newborns with acute heart failure and pulmonary hypertension in the absence of any underlying heart malformation and/or previous cardiosurgical procedures. During the neonatal period, levosimendan may represent an ideal drug for immature myocardium characterized by a higher calcium-dependent contractility than in adults.

Isolated pericardial agenesis revealed by bradycardia and heart MRI in a healthy 5-year-old child

We present a five-year-old boy with an unremarkable medical history who was incidentally found to have bradycardia and electrocardiographic signs of right axial deviation. Initial echocardiogram showed left displacement of the cardiac apex with slight enlargement of the right ventricle, while frontal chest radiograph showed a lucent area between the aorta and pulmonary artery. Cardiac magnetic resonance imaging finally revealed a partial left pericardial agenesis and abnormal displacement of the heart into the left hemithorax.

Is the prophylaxis of patent ductus arteriosus useful in extremely premature infants?

This study was aimed to verify the efficacy and safety of ibuprofen prophylaxis of patent ductus arteriosus in very preterm infants, in order to select infants receiving higher benefits from this intervention. Two hundred neonates with gestational age (GA) < or = 28 weeks receiving ibuprofen within the first two hours of life were included. Ductus closure rate was 68%, and results were significantly dependent on GA (48.8% among neonates with GA < 26 weeks vs 73.2% among those with GA > or = 26 weeks, p < 0.01). Neonates with GA < 26 weeks showed a lower ductus closure after the primary course of therapy (20% vs 57.5%, p < 0.01), as well as higher reopening rate (16.2% vs 3.8%, p < 0.05) and need for surgical ligation (38.8% vs 5.8%, p < 0.01). During the prophylaxis period, 11 neonates (5.5%) showed pulmonary hypertension. Considering risks/benefits, we recommend prophylaxis only in infants with GA < 26 weeks.

Hypertrabecular aspect of left ventricular myocardium: a possible complication of congenital hypothyroidism in a preterm infant

We report a case of hypertrabeculated left ventricular myocardium associated with congenital hypothyroidism in a preterm infant. The myocardical anomalies and long QT interval, absent at birth, appeared simultaneously to abnormal thyroid hormones and progressively improved until complete recovery during Levo-Thyroxine treatment. We speculate that thyroid dysfunction could be the potential cause of transient hypertrabecular aspect of the left ventricle.

Responsiveness to intravenous immunoglobulins and occurrence of coronary artery abnormalities in a single-center cohort of Italian patients with Kawasaki syndrome

Clues to predict the response to intravenous immunoglobulins (IVIG) and the development of coronary artery abnormalities (CAA) in children with Kawasaki syndrome (KS) are still undefined. We examined retrospectively the medical charts of children hospitalized between February 1990 and April 2009 with diagnosis of KS. A total of 32 Italian patients with a mean age of 23.8 months were analyzed and all received IVIG according to two schemes: 0.4 g/(kg day) for 5 days or 2 g/kg in a single infusion, combined with oral acetylsalicylic acid. General, clinical and laboratory data were registered. Each patient was evaluated with echocardiography at admission, then with 3-day and weekly frequency, respectively, during hospital stay and for the first 6-8 weeks since onset, and finally with a regular 6-12 month follow-up over time, according to patient risk stratification. Five patients showing significantly higher values of C-reactive protein (CRP) at admission were IVIG-resistant after the first infusion (P = 0.04) in comparison with the remaining 27. Five patients out of 32 developed CAA, with no statistical significance when analyzed for IVIG dosage or IVIG-resistance. The demonstration of CAA was significantly higher in children aged <12 months (P = 0.037). Our experience, limited to a single-center cohort of 32 patients with KS, though treated with two different IVIG schemes, has shown that higher values of CRP and younger age at onset are nodal points in determining, respectively, a failure in the response to IVIG and an increased occurrence of CAA.

Atypical manifestations of congenital parvovirus B19 infection

Parvovirus B19 infection in pregnancy is associated with fetal anemia, hydrops and fetal death. We report two unusual manifestations of vertical parvovirus B19 infection. The first patient developed hydrops as consequence of myocarditis with involvement of sino-atrial node. The other had pleural effusion reactive to the hepatic localization of the virus.

Cardiac complications in preterm infants with percutaneous long lines: the importance of early diagnosis

Percutaneous long lines, routinely used in preterm infants, can be associated with several cardiac complications such as pericardial effusion and consequent cardiac tamponade. We report three patients with pericardial effusion highlighting the importance of cardiac ultrasound monitoring to both early diagnosis and treatment.

Cardiac magnetic resonance of healthy children and young adults with frequent premature ventricular complexes

OBJECTIVE

To assess whether magnetic resonance imaging could detect any cardiac morphological or functional myocardial alterations in healthy children and young adults with ventricular arrhythmias.

METHODS

Twenty-three subjects (14 male, mean age 15.6 +/- 6.5 years) with frequent (> or =30/h) premature ventricular complexes (PVCs) on Holter monitoring and normal echocardiographic and electrocardiographic findings underwent cardiac magnetic resonance (CMR) on a 1.5T scanner and an exercise stress test. Subjects were also followed up for a period of 71 +/- 24 months.

RESULTS

CMR showed no evidence of structural cardiac abnormalities, but functional assessment revealed significant impairment in 17 subjects (74%): mild to moderate right ventricular enlargement was found in all of these subjects associated with a mild reduction of ventricular function in five cases (22%) and mild free wall and/or apex contraction abnormalities in eight subjects (35%). PVCs persisted during stress test in three subjects (13%) and disappeared in 19 (83%). No serious cardiac event was observed during the follow-up.

CONCLUSIONS

Our study shows that subjects with PVCs without detectable electrocardiographic and echocardiographic abnormalities frequently exhibit functional impairment of the right ventricle at CMR, potentially responsible for ventricular arrhythmias. Although the causes of these abnormalities remain to be elucidated, the long-term outcome of these subjects is excellent.

Large pericardial effusion requiring pericardiocentesis as cardinal sign of macrophage activation syndrome in systemic onset-juvenile idiopathic arthritis

We report a case of large pericardial effusion which has been managed with pericardiocentesis as the main presentation feature of a dramatic clinical picture, only retrospectively framed as referred to macrophage activation syndrome in a child with juvenile idiopathic arthritis at its onset. The risk of developing this rare and severe complication should be recognized in various pathological settings of childhood, above all in children displaying systemic signs of juvenile idiopathic arthritis.

Exercise-unrelated sudden death as the first event of anomalous origin of the left coronary artery from the right aortic sinus

Congenital anomalous origins of the coronary arteries represents a rare but well-described cause of myocardial ischemia and sudden death. Left coronary artery (LCA) arising from the right sinus of Valsalva is a rare congenital coronary anomaly that seems to be commonly associated with sudden death in young trained athletes. The possibility of a coronary artery anomaly should always be considered in young individuals with a history of chest pain or syncope, particularly if the episodes are triggered by exercise. We describe a case of congenital LCA anomaly in an asymptomatic 10-year-old girl with no family history of sudden death; no previous unexplained syncopal episodes or exercise-induced symptoms were reported. She experienced a cardiac arrest while she was resting at school and was not recoverable despite early emergency department admission and intensive prolonged cardiopulmonary resuscitation attempts. Post-mortem pathological findings revealed a single origin from the right sinus of Valsalva for both right and left coronary arteries. The LCA was compressed between the aorta and the pulmonary trunk. Histologic features suggested recent ischemia. Although sudden death can be the first manifestation of this condition, it is important to be particularly aware of prodromic symptoms: exertional dyspnea, chest pain, syncope or dizziness. Recognition during life of this coronary anomaly is mandatory to prevent the risk of sudden death and to plan surgical correction if clinically indicated.

Illness understanding in adults with congenital heart disease

BACKGROUND

Adult patients with congenital heart disease need information regarding their clinical diagnosis, medications and side effects, endocarditis prophylaxis, reproductive issues, employment, future surveillance, treatments, and possible reoperations. Accurate understanding of chronic illness in these patients is associated with less distress, less confusion, improved satisfaction with medical care, better compliance with treatment, and a better emotional status, all key factors for good health-related quality of life. The aim of the present study was to assess the level of knowledge that adult patients with congenital heart disease followed in our Center have about their heart condition.

METHODS

A questionnaire on knowledge about congenital heart disease was sent by mail to 200 adults affected by a cardiac congenital disease chosen randomly from all patients regularly followed in our department.

RESULTS

Patients had good knowledge about the treatment received, the importance of follow-up, the prognosis of their condition, and the possibility of taking part in physical activities. The patients receiving drug treatment were moderately knowledgeable about their treatment. The anatomy of the heart defect, factors contributing to the onset of endocarditis, the impact of smoking and alcohol, and the possible inheritance of the heart condition were poorly understood by the patients. Most of female patients knew that the oral contraceptive pill was the most appropriate method of birth control; most of them were aware that pregnancy would cause additional risks to their health. Multiple logistic analysis showed that four correct answers were related to the age of the patient.

CONCLUSIONS

Overall the results indicated that the educational efforts of all the staff (physicians and nurses) have given encouraging results, but there are still significant gaps in knowledge that need more educational work.

Fatal coronary artery anomaly presenting as bronchiolitis

During winter outbreaks of respiratory syncytial virus bronchiolitis from 2002 to 2004, three infants presented with a presumptive diagnosis of lower respiratory tract infection and wheezing. The clinical condition in two cases was rapidly progressive and precipitated into intractable shock; clinical and instrumental examinations revealed a cardiac origin of their illness. A subacute presentation permitted a cardiological assessment and a proper treatment in the third infant. An abnormal origin of the left coronary artery from the pulmonary trunk was demonstrated in all cases. The concurrent acute airway infection had a catastrophic effect on the underlying cardiovascular anomaly leading to refractory cardiogenic shock and death.

CONCLUSION

Admission chest X-ray film and arterial gas analysis can raise the suspicion of cardiac involvement when treating a severe wheezing episode in young infants. Paediatric cardiological evaluation with two-dimensional echocardiography may eventually reveal this rare condition, whereas cardiac catheterisation with aortography remains the standard means of diagnosis.

What do parents know about the malformations afflicting the hearts of their children?

Traditionally, medical professionals have entrusted the parents of children with chronic illness with the task of imparting knowledge about the illness to the children. This practice assumes that parents understand the illness, and that they pass on their knowledge in a manner appropriate for the individual child. The aim of our study was to assess the knowledge that parents of children with a cardiac defect have about the malformation in the heart of their child. We sent a modified version of the Leuven questionnaire to 350 families. The questionnaire was filled in and sent back to our centre by 148 families. Parents showed a good knowledge of the name and anatomical characteristics of the cardiac disease suffered by their child. Parents with a child taking drugs were not very knowledgeable about the regime, side effects, and interaction with other drugs or food. Only one-quarter of the parents knew the definition of endocarditis, although almost two-fifths were aware that unexplained fever for more than 5 days was the most typical symptom. Less than half of the parents knew that endocarditis could recur. About two-fifths of parents knew the real possibility of their child being involved in competitive sports; but almost half of parents were unable to answer this question. The poor knowledge about particular aspects of the disease, treatment, and preventive measures revealed by our parents may have major consequences. The results of our study are relevant to general daily clinical practice.

Recombinant interferon gamma lb and low dose steroid in two pediatric cases of nonspecific interstitial pneumonia

We report two young girls, the first almost 18 years old and the second 12 1/2 years old, affected with nonspecific interstitial pneumonia, both diagnosed at the age of 11 by open lung biopsy and both being treated with low-dose steroid. Due to insufficient response to conventional therapy and based on positive therapeutic results following the use of subcutaneous recombinant interferon gamma-1b in fibrosing interstitial pneumonias of adults, they were given a 1-year trial of subcutaneous recombinant interferon gamma-lb in association with a steroid. Our experience with these two young patients suggests that interferon gamma-lb cannot be considered as stabilizing or a curative therapy to control or reverse nonspecific interstitial pneumonia unresponsive to steroids alone.

Catecholaminergic polymorphic ventricular tachycardia: successful emergency treatment with intravenous propranolol

Catecholaminergic polymorphic ventricular tachycardia (VT) is a rare arrhythmogenic disorder, which may cause sudden death and whose relationships with mutations in cardiac ryanodine receptor gene have been recently established. The present article reports a catecholaminergic polymorphic VT case of a 9-year-old girl, without any previous history of syncope, who has been found unconscious while playing and referred comatose to pediatric intensive care unit. The electrocardiogram pattern showed runs of bidirectional and polymorphic VT degenerating into ventricular fibrillation, without QT interval abnormalities. Various attempts of cardioversion, lidocaine, and magnesium sulfate intravenous infusions were only partially effective. Owing to catecholaminergic polymorphic VT highly suggesting electrocardiogram pattern, intravenous propranolol was administered, achieving immediate VT interruption. Long-term nadolol therapy effectively prevented further arrhythmias, with no relapses up to 10 months later; a good neurologic recovery was also obtained. Genetic evaluation revealed in this patient-but not in relatives-a mutation in ryanodine receptor gene on chromosome 1.

Transcatheter closure of atrial septal defect in young children: results and follow-up

OBJECTIVES

This study sought to analyze the safety, efficacy, and follow-up results of percutaneous closure of secundum atrial septal defect (ASD) in young children.

BACKGROUND

Results of ASD transcatheter closure in adults are widely reported but there are no large published series concerning young children.

METHODS

Between December 1996 and February 2002, 48 of 553 patients percutaneously treated at our institution were children age <or=5 years. Indications for closure were: elective closure in 32 patients; frequent respiratory infections in 8; failure to thrive in 2; liver transplantation in 5; and a fenestrated Fontan in 1. The procedure was carried out under general anesthesia with fluoroscopy and transesophageal control. Two different devices were used: 1) the CardioSEAL/StarFLEX (CS/SF) and 2) the Amplatzer septal occluder (ASO). Basal physical examinations and echocardiograms were performed prior to the procedure and at follow-ups (1, 6, and 12 months, and yearly thereafter).

RESULTS

The mean age at closure was 3.6 +/- 1.3 years. A CS/SF was used in 10 subjects; an ASO was used in 38 patients. No deaths or immediate major complications occurred. The total occlusion rate was 87% at procedure, rising to 94% at discharge. The mean follow-up was 18 +/- 14 months. No midterm major or minor complications occurred. The occlusion rate rose to 100% at 12 months of follow-up. Symptomatic patients improved significantly.

CONCLUSIONS

In the current era and in experienced hands, ASD closure can be performed safely and successfully, even in very young children.

Role of heart rate variability in the early diagnosis of diabetic autonomic neuropathy in children

BACKGROUND

Diabetic autonomic neuropathy (DAN) is a major complication of diabetes. DAN has been shown to be closely related to glycemic control. To contribute significantly to the morbidity and mortality of the disease, and to be indicative of an increased risk of cardiovascular events. Tests assessing the function of the autonomic nervous system, such as the response of heart rate and blood pressure to maneuvers stimulating the autonomic nervous system, including deep breathing. Valsalva maneuver and standing, allowed to detect signs of DAN in adolescents; however, the sensitivity of such tests in revealing an early impairment of the autonomic nervous system proved low. Several studies found heart rate variability (HRV) to be useful in assessing the dysfunction of the autonomic nervous system in diabetic children and adolescents, but only few HRV parameters were evaluated in most of them.

OBJECTIVE

To study cardiac autonomic nervous system in diabetic children, and to investigate whether the duration of diabetes and the degree of metabolic control are determinants for the development of DAN in children.

PATIENTS AND METHODS

We analyzed HRV in 50 asymptomatic patients with insulin-dependent diabetes mellitus (IDDM) and 30 healthy children matched for age and sex.

RESULTS

Patients with a history of diabetes > 8 years showed significant alterations of the autonomic nervous system (significant reduction of r-MSSD, pNN50, HF and increase in LF/HF). Conversely, only a reduction in pNN50 was found in patients with a disease duration < 8 years. Furthermore, we also observed significant HRV abnormalities in patients with an impaired metabolic control of diabetes. Compared to controls, patients with glycosylated hemoglobin blood levels (HbA(1C)) > 8% showed a significant reduction of r-MSSD, pHH50 and total power spectrum, whereas no HRV abnormalities were detected in patients with an HbA(1C) < 8%.

CONCLUSIONS

HRV analysis can detect early subclinical alterations of the autonomic nervous system in asymptomatic patients with IDDM, which seem to consist mainly in a parasympathetic impairment. Autonomic dysfunction is associated both with the duration and an inadequate metabolic control of the disease.

Differential diagnosis between patent foramen ovale and pulmonary arteriovenous fistula in two patients with previous cryptogenic stroke caused by presumed paradoxical embolism

Development of improved devices for interventional closure of atrial septal defect and patent foramen ovale increased the number of adult patients who are being referred for transcatheter closure. We report two cases that were scheduled for patent foramen ovale closure because of a right-to-left atrial shunt detected at contrast transesophageal echocardiography in another institution and that were found to have pulmonary arteriovenous fistulas. Embolization of pulmonary arteriovenous fistulas was carried out successfully by transcatheter technique.

Prognostic factors and outcome of children with severe head injury: an 8-year experience

OBJECTIVES

Our aim was to analyze prognostic factors and their association with outcome among children with severe head injury.

METHODS

We conducted a retrospective study among children with severe head injury admitted to our Pediatric Intensive Care Unit (PICU) from November 1992 to December 2000. The patients were immediately evaluated for the severity of head injury (Glasgow Coma Score, GCS), clinical presentation, cerebral axial tomography, early complications (hypoxia and hypotension), metabolic and hematological alterations and early post-traumatic seizures. Six months after injury we applied the Glasgow Outcome Score (GOS). Correlations with GOS were evaluated using univariate and multivariate logistic models.

RESULTS

In all, 122 children with severe head injury were identified. The patients presented the following scores: 18 (14.7.0%) children had a GOS of 1; 2 had a GOS of 2 (1.6%); 27 (22.2%) a GOS of 3 and 75 (61.5%) a GOS of 4 or 5. A low GOS was significantly and independently associated with low GCS, multiple trauma, the presence of hypoxia and hypotension, disseminated intravascular coagulation (DIC), hyperglycemia and early post-traumatic seizures. Hematological alterations (white blood cells) were also associated with a low GOS, though not significantly.

CONCLUSION

In addition to GCS, types of trauma and brain lesion, hypoxia and hypotension, hemocoagulative disorders (DIC), hyperglycemia and early post-traumatic seizures are predictors of GOS. A knowledge of these prognostic factors and the correct management of children with severe head injury helps clinicians to improve outcome and to reduce morbidity and mortality.

Influence of the co-encapsulation of different non-ionic surfactants on the properties of PLGA insulin-loaded microspheres

The aim of this work was to produce insulin-loaded microspheres allowing the preservation of peptide stability during both particle processing and insulin release. Our strategy was to combine the concepts of using surfactants to improve insulin stability while optimising overall microsphere characteristics such as size, morphology, peptide loading and release. Bovine insulin was encapsulated within poly(lactide-co-glycolide) (PLGA 50:50, Resomer RG504H) microspheres by the multiple emulsion-solvent evaporation technique. Microspheres were prepared by adding to the primary emulsion three non-ionic surfactants, poloxamer 188, polysorbate 20 and sorbitan monooleate 80, at different concentrations (1.5 and 3. 0% w/v). The presence of surfactants was found to decrease the mean diameter and to affect the morphology of the microspheres. Insulin encapsulation efficiency was reduced in the presence of surfactants and especially for sorbitan monooleate 80, in a concentration-dependent mode. The influence of the surfactants on the interactions between insulin and PLGA together with the primary emulsion stability were found to be the major determinants of insulin encapsulation. The release of insulin from microspheres was biphasic, showing an initial burst effect followed by a near zero-order release for all the batches prepared. The initial burst was related to the presence of insulin molecules located onto or near to the microsphere surface. In the presence of surfactants, a faster insulin release with respect to microspheres encapsulating insulin alone was observed. Insulin stability within microspheres after processing, storage and release was evaluated by reversed phase- and size-exclusion-HPLC. The analysis of microsphere content after processing and 6 months of storage showed that insulin did not undergo any chemical modification within microspheres. On the contrary, during the period of sustained release insulin was transformed in a high-molecular weight product, the amount of which was related to the surfactant used. In conclusion, polysorbate 20 at 3% w/v concentration was the most effective in giving regular shaped particles with both good insulin loading and slow release, and limiting insulin modification within microspheres.