Cause‐Specific Mortality in Patients During Long‐Term Follow‐Up After Atrial Switch for Transposition of the Great Arteries

Background

Little is known about the cause of death (CoD) in patients with transposition of the great arteries palliated with a Mustard or Senning procedure. The aim was to describe the CoD for patients with the Mustard and Senning procedure during short‐ (<10 years), mid‐ (10–20 years), and long‐term (>20 years) follow‐up after the operation.

Methods and Results

This is a retrospective, descriptive multicenter cohort study including all Nordic patients (Denmark, Finland, Norway, and Sweden) who underwent a Mustard or Senning procedure between 1967 and 2003. Patients who died within 30 days after the index operation were excluded. Among 968 patients with Mustard/Senning palliated transposition of the great arteries, 814 patients were eligible for the study, with a mean follow‐up of 33.6 years. The estimated risk of all‐cause mortality reached 36.0% after 43 years of follow‐up, and the risk of death was highest among male patients as compared with female patients ( P =0.004). The most common CoD was sudden cardiac death (SCD), followed by heart failure/heart transplantation accounting for 29% and 27%, respectively. During short‐, mid‐, and long‐term follow‐up, there was a change in CoD with SCD accounting for 23.7%, 46.6%, and 19.0% ( P =0.002) and heart failure/heart transplantation 18.6%, 22.4%, and 46.6% ( P =0.0005), respectively.

Conclusions

Among patients corrected with Mustard or Senning transposition of the great arteries, the most common CoD is SCD followed by heart failure/heart transplantation. The CoD changes as the patients age, with SCD as the most common cause in adolescence and heart failure as the dominant cause in adulthood. Furthermore, the risk of all‐cause mortality, SCD, and death attributable to heart failure or heart transplantation was increased in men >10 years after the Mustard/Senning operation.

Procedural risk factors, incidence and timing of reintervention after treatment for native coarctation of the aorta in children: a population-based study†

OBJECTIVES

The aim of the present study was to evaluate procedural risk factors, incidence and timing of reintervention because of recurrent aortic coarctation in children.

METHODS

The study cohort consisted of 304 patients with isolated coarctation: 251 underwent surgery and 53 were treated percutaneously (40 balloon angioplasty, 13 stent) at the Helsinki Children's Hospital in 2000-2012. Characteristics, intervention and reintervention data were retrospectively collected from clinical records until 2014 (median follow-up 7.9 years). Age- and sex-matched comparisons between the treatment groups were performed in 86 patients (surgery n = 43, percutaneous n = 43).

RESULTS

Forty of the 251 (16%) patients after surgery, 9/40 (23%) patients after balloon angioplasty and 4/13 (31%) patients after stent placement underwent a reintervention after a median time of 3.4, 11.7 and 19.5 months (P < 0.05), respectively. In the surgery group, all reinterventions occurred in children operated on ≤12 months of age and were related to lower body weight and smaller dimensions of the aorta. In the balloon angioplasty group, a higher post-procedure systolic arm-leg blood pressure gradient was associated with reintervention. After stent placement, three-fourths of the reinterventions were performed in a planned postinterventional catheterization. In the age- and sex-matched comparisons (median 5,7 years, range 0,5-17,6), post-procedure blood pressure gradients were higher (mean 10 vs 4 mmHg, P = 0.03), and reinterventions were more common (28%, 95% confidence interval 17-43 vs 2%, 95% confidence interval 0-12) in the percutaneous group compared to the surgery group.

CONCLUSIONS

Reinterventions after surgery in neonates were relatively common. In older children, percutaneous treatment carried a higher risk of reinterventions, which were mainly related to residual coarctation after primary treatment.

Late outcome after paediatric heart transplantation in Finland

OBJECTIVES

We studied the long-term survival and rejection episodes of paediatric heart transplant recipients.

METHODS

We included all paediatric patients (≤18 years) who underwent heart transplantation during 1991-2014 in Finland. Data were obtained retrospectively from a paediatric cardiac surgery database. Patient status was received from the Finnish population registry. All patients underwent yearly routine postoperative endomyocardial biopsies and coronary angiographies.

RESULTS

Between 1991 and 2014, 68 heart transplantations were performed. The early mortality (<30 days after surgery) rate was 10% and follow-up coverage was 100%. The 10- and 15-year survival rates for all patients were 68% (95% confidence internal, CI, 56-80%) and 65% (95% CI 53-78%), respectively, including early mortality. The 1-year survival rate was 100% when excluding early operative mortality. Indications for heart transplantation were cardiomyopathy in 57% and cardiac malformations in 43% of patients, with similar long-term survival between the groups. During 23 years of follow-up, 43 patients (70%) had at least one rejection episode and 17 patients (29%) at least a grade 1 coronary artery vasculopathy finding. Patients with early rejection episodes (<3 months) had a higher incidence of late rejection episodes (P = 0.025). Older age at operation was a significant risk factor for the development of coronary artery vasculopathy (hazard ratio 1.1, 95% CI 1.0-1.3, P = 0.012).

CONCLUSIONS

First-year survival was excellent. Asymptomatic rejection episodes were common among patients. Early rejection episodes are a risk factor for late rejection episodes and show a trend towards an increased risk of late death. Coronary artery vasculopathy remains a major challenge for late graft survival.

Long-term results of the Ross procedure in a population-based follow-up

OBJECTIVES

The purpose of this study was to evaluate the long-term outcomes of the Ross procedure in a nationwide follow-up.

METHODS

This retrospective study involved all children treated with the Ross procedure in Finland between 1994 and 2009. The clinical records were reviewed for demographic and anatomical characteristics, Ross operation data, surgical history and status at the latest follow-up. The median follow-up time was 11.5 (range 2.4-19.2) years.

RESULTS

Fifty-one patients underwent either the Ross (n = 37) or the Ross-Konno (n = 14) procedure at a median age of 4.8 (range 0.02-16.3) years, including 13 infants (<1 year of age). The indication for the Ross procedure was aortic valve stenosis, regurgitation or both, which was observed in 29, 24 and 47% of patients, respectively. The early mortality (before hospital discharge) rate was 10% (31% in infants) and the late mortality rate 6% (15% in infants). Higher mortality was discovered in patients treated with the Ross-Konno procedure (P = 0.001). The most common cause for reintervention was pulmonary homograft stenosis. The rate of freedom from right ventricular outflow tract reintervention was 98% at 5 years, 83% at 10 years and 59% at 15 years. The rate of freedom from autograft reintervention was 98% at 5 and 10 years, and 81% at 15 years. At the latest follow-up visit, mild-to-moderate aortic root dilatation was reported in 52% of patients, and 4 patients had undergone autograft-related reinterventions. Trivial autograft valve regurgitation was commonly seen, but only 1 patient developed severe autograft regurgitation requiring mechanical valve replacement 15.9 years after the Ross operation.

CONCLUSIONS

The most common reason for reintervention after the Ross procedure in children is homograft stenosis. Aortic root dilatation and autograft valve regurgitation are relatively common but rarely lead to reinterventions before adulthood. Intraoperative complications and complex cardiac anatomy are associated with high mortality in infants undergoing the Ross-Konno procedure. In our centre, the Ross procedure has provided good long-term results in this challenging group of paediatric patients.

Late gadolinium enhancement (LGE) progresses with right ventricle volume in children after repair of tetralogy of fallot

Background

Fibrosis after myocardial damage can be determined by cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE). We studied whether ventricular LGE is visible in the ventricles of pediatric and adolescent TOF (tetralogy of Fallot) patients by measuring LGE and investigating whether fibrosis correlated with right ventricular volume, pulmonary regurgitation, N-terminal pro-brain natriuretic peptide (NT-proBNP) or the aminoterminal propeptide of type III procollagen (PIIINP). We also studied if the patient's age, post-operative follow-up time or surgical history would affect LGE.

Methods

A total of 40 pediatric patients who had undergone TOF repair and 43 healthy age and gender matched controls underwent a CMR study, whereby LGE was scored in the right (RV) and the left ventricle. To exclude the possible iatrogenic scarring we calculated the LGE score by excluding the right ventricular outflow tract and VSD patch region.

Results

All patients had RV LGE and in 39 of 40 it was seen also outside the surgically affected areas. The amount of LGE correlated positively with the RV end-diastolic volume (r = 0.44, P = 0.0045), pulmonary regurgitation (r = 0.40, P = 0.013), and with NT-proBNP. The presence of LGE also depended on post-operative follow-up time (r = 0.53, P = 0.006). PIIINP levels of TOF patients were significantly higher than in the control subjects but it did not correlate with LGE or with any of the studied clinical markers.

Conclusions

LGE is present globally in the right ventricular muscle in children and adolescents with TOF. The longer the follow-up time the more common was the LGE in the right ventricle.

Cardiac troponin I, cardiac troponin-specific autoantibodies and natriuretic peptides in children with hypoplastic left heart syndrome

OBJECTIVES

To evaluate serum levels of cardiac troponin I (cTnI), autoantibodies against cardiac troponin (cTnAAbs) and natriuretic peptides during the treatment protocol in children with hypoplastic left heart syndrome (HLHS).

METHODS

In a prospective study, we had 18 consecutive children with HLHS, for whom serum samples were analysed before the Norwood operation, before the bidirectional Glenn (BDG) operation, at the age of one year and before total cavo-pulmonary connection (TCPC). In addition, we performed a cross-sectional study in 22 children examined before TCPC. Controls comprised 34 healthy children.

RESULTS

In the prospective study, troponin I was positive in eight children before the Norwood operation. At the next follow-up, six children were positive. Thereafter, in all samples, cTnI was negative. Serum levels of natriuretic peptides decreased during the treatment protocol but remained higher than in controls throughout the study. In the cross-sectional study, cTnI levels were negative, but levels of natriuretic peptides were higher than in controls. Levels of cTnI and natriuretic peptides showed no correlation with oxygen saturation or haemoglobin concentration. Autoantibodies against cardiac troponin appeared in one patient but not in the control children.

CONCLUSIONS

Cardiac TnI release is common before Norwood and BDG operations; then during the treatment protocol for HLHS, cTnI release resolves and serum levels of natriuretic peptides decrease. This may reflect a reduction of volume overload of the right ventricle during the surgical programme.

Outcome of pediatric heart transplantation recipients treated with ventricular assist device

This study was conducted to evaluate the long-term prognosis of pediatric HTx patients treated with VAD before transplantation. The clinical data of six patients bridged to HTx with Berlin Heart EXCOR pediatric device were analyzed retrospectively. Information about graft function, CA results, and EMB findings as well as appearance DSA was collected. Also, information about growth and cognitive function was analyzed. These findings were compared with age-, gender-, and diagnosis-matched HTx patients. During the median follow-up time of four and half yr after HTx, the prognosis including graft function, number of rejection episodes, and incidence of coronary artery vasculopathy, growth and cognitive development did not differ between VAD-bridged HTx patients compared with control patients. In both groups, one patient developed positive DSA titer after HTx. Our single-center experience suggests that the prognosis of pediatric HTx patients treated with VAD before transplantation is not inferior to that of other HTx patients.

Surgery for Primary Cardiac Tumors in Children

Background—

To evaluate indications and results of surgery for primary cardiac tumors in children.

Methods and Results—

Eighty-nine patients aged ≤18 years undergoing surgery for cardiac tumor between 1990 and 2005 from 16 centers were included retrospectively (M/F=41/48; median age 4.3 months, range 1 day to 18 years). Sixty-three patients (68.5%) presented with symptoms. Surgery consisted of complete resection in 62 (69.7%) patients, partial resection in 21 (23.6%), and cardiac transplant in 4 (4.5%). Most frequent histotypes (93.2%) were benign (rhabdomyoma, myxoma, teratoma, fibroma, and hemangioma). Postoperative complications occurred in 29.9%. Early and late mortality were 4.5% each (mean follow-up, 6.3±4.4 years); major adverse events occurred in 28.2% of the patients; 90.7% of patients are in New York Heart Association class I. There were no statistically significant differences in survival, postoperative complications, or adverse events after complete and partial resection in benign tumors other than myxomas. Cardiac transplant was associated significantly with higher mortality rate ( P= 0.006). Overall mortality was associated to malignancy ( P =0.0008), and adverse events during follow-up ( P =0.005).

Conclusions—

Surgery for primary cardiac tumors in children has good early and long-term outcomes, with low recurrence rate. Rhabdomyomas are the most frequent surgical histotypes. Malignant tumors negatively affect early and late survival. Heart transplant is indicated when conservative surgery is not feasible. Lack of recurrence after partial resection of benign cardiac tumors indicates that a less risky tumor debulking is effective for a subset of histotypes such as rhabdomyomas and fibromas.

Regulatory T cell defect in APECED patients is associated with loss of naive FOXP3(+) precursors and impaired activated population

The pathogenetic mechanisms of organ-specific autoimmune diseases remain obscured by the complexity of the genetic and environmental factors participating in the breakdown of tolerance. A unique opportunity to study the pathogenesis of human autoimmunity is provided by autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), a rare inherited autoimmune disease caused by mutations in Autoimmune Regulator (AIRE) gene. Loss of AIRE function disrupts the deletion of autoreactive T cells and impairs the suppressive function of regulatory T (Treg) cells. Here we show by multiparameter flow cytometry that in healthy controls the peripheral naive Treg cell subset forms a slowly dividing, persistent reservoir of recent thymic emigrants (RTEs). In APECED patients the RTE Treg cells show accelerated turnover and shift to the activated pool and the RTE reservoir is depleted. Moreover, the activated Treg cell population in the patients expresses significantly less Forkhead box protein P3 (FOXP3) than in the healthy controls, consistent with the impairment of peripheral activation. Our results indicate that in addition to their thymic effects, loss-of-function mutations in AIRE disrupt the peripheral homeostasis and activation of Treg cells. This may synergize with failed negative selection to cause APECED.

High survival rates after liver transplantation for hepatoblastoma and hepatocellular carcinoma

Unresectable malignant liver tumors may be treated by LTx. We evaluated the results of LTx for HB and HCC. All patients transplanted for HB or HCC between 1990 and 2007 were included. Effects of histologic tumor type, primary tumor resection, disease staging, and serum AFP levels at diagnosis and at transplantation on disease recurrence and survival were evaluated. Twelve patients with median age of five (range, 2-16) were transplanted and followed for a median of 11 (2-18) yr. Six patients had HB and six had HCC. At diagnosis, eight patients were staged as PRETEXT III and four patients as PRETEXT IV. Two patients had pulmonary metastases. All patients received neoadjuvant chemotherapy. Median time from diagnosis to LTx was seven (2-133) months. At LTx, none of the patients had radiological evidence of extrahepatic disease, and the median AFP level was 85 (6-15 180) microg/L. No routine chemotherapy after LTx was used.The overall one-, five-, and 10-yr cumulative survival rates were 100%, 80%, and 67%, respectively. Survival was comparable between the two tumor types (4/6 for both). Two deaths occurred secondary to tumor recurrence, one of each tumor type. Both of these patients had an AFP response of <99%. Six of eight patients with primary LTx survived, when compared to two of four transplanted after primary resection. PRETEXT tumor staging had no effect on survival. LTx even without post-transplantation chemotherapy is an effective treatment option for unresectable HB and HCC with comparable survival. Incomplete AFP response to chemotherapy and primary tumor resection were associated with decreased survival.

The CD4(+)CD8(+) and CD4(+) subsets of FOXP3(+) thymocytes differ in their response to growth factor deprivation or stimulation

The timing of thymic regulatory T (Treg) cell commitment remains unclear. Specifically, there is disagreement as to whether the CD4(+)CD8(+) FOXP3(+) thymocytes are precursors of mature CD4(+) FOXP3(+) Treg cells, or an independent Treg cell lineage. We reasoned that precursors should be more susceptible to apoptosis than mature Treg cells, and tested this by growth factor removal and anti-CD3 stimulation. Both treatments resulted in an increase of CD4(+) FOXP3(+) thymocytes, whereas the frequency of CD4(+)CD8(+) FOXP3(+) thymocytes decreased significantly. These changes were accompanied by an increase of annexin(+) apoptotic cells. Both of these FOXP3(+) subsets expressed higher levels of Bcl-2 and BIM than other thymocytes, and while in our setting expression of BIM seemed to predispose the cells to apoptosis, Bcl-2 had no apparent protective effect. These results indicate that CD4(+)CD8(+) FOXP3(+) thymocytes are more susceptible to apoptosis than mature CD4(+) FOXP3(+) Treg cells. This is consistent with the view that they are still immature and thus likely to represent a precursor population.

Increased incidence of Hirschsprung's disease in patients with hypoplastic left heart syndrome--a common neural crest-derived etiology?

BACKGROUND

The enteric ganglions and the outflow tract of the heart originate from the neural crest. Impaired migration or differentiation of the neural crest cells causes Hirschsprung's disease (HD) and results in the development of cardiac outflow tract malformations. We hypothesize that the incidence of HD and bowel disorders associated with HD are increased in patients with hypoplastic left heart syndrome (HLHS) including left cardiac outflow tract obstruction.

METHODS

All consecutive patients treated for HLHS at our institution during 1969 to 2005 were retrospectively reviewed. The number of patients with histologically confirmed HD or clinical findings characteristic of HD such as constipation and delayed meconium were recorded from the patient records.

RESULTS

A total of 113 patients (65 males) were identified. At the time of survey, 57 patients (51%) were alive. Overall, there were 26 (23%) patients with constipation, and 9/23 (39%) had delayed passage of meconium after 48 hours. Despite frequent bowel disorders only 4 (3.5%) patients had undergone histologic examination of the rectum. Hirschsprung's disease was detected in 3 patients (95% confidence interval, 0.62-8.77). The expected number of HD cases in the study population was 0.026 giving 117-fold significant increase in the incidence of HD among patients with HLHS when compared to general Finnish population.

CONCLUSIONS

The incidence of HD is increased in patients with HLHS. These results point to a common neural crest-derived embryologic origin of HD and HLHS and warrant further studies.

[Single-ventricle heart defects--long-term prognosis, late complications and quality of life]

Treatment of a single-ventricle heart defect involves redirecting of systemic venous blood returning to the heart to gradually flow directly into the pulmonary artery without the functional right side of the heart being involved. In developed countries, three out of four persons with this ailment will nowadays reach adulthood. Among these, at least one out of four presents significant associated problems and late complications. The most significant problems include heart failure, arrhythmias, cyanosis and thromboembolic complications that increase over time. In addition to these, neurological complications have an influence on the quality of life in some patients.

Nosocomial infections after pediatric cardiac surgery

BACKGROUND

This study examined the rate of nosocomial infection (NI) in children who underwent cardiac surgery, and also investigated the impact of postdischarge infection surveillance. Risk factors for surgical site infections (SSIs) also were evaluated.

METHODS

All patients who underwent open-heart cardiac surgery in the Hospital for Children and Adolescents, Helsinki University Central Hospital, Finland, between January 2000 and December 2002 were included. Data were collected retrospectively from hospital registries. A prospective postdischarge survey was conducted to detect SSIs arising within 30 days after surgery, as well as respiratory and gastrointestinal infections with onset within 3 days after discharge.

RESULTS

The study included 614 procedures performed in 511 patients. A total of 80 NIs were found (overall NI rate, 6.3 per 1000 patient days), including 21 superficial and 6 deep SSIs. Multivariable analysis identified preoperative hospitalization > 48 hours and high American Society of Anesthesiologists (ASA) score as risk factors for SSI. The postdischarge study revealed 7 additional superficial SSIs, 29 respiratory infections, and 29 gastrointestinal infections; 12 patients required rehospitalization.

CONCLUSIONS

Almost 25% of the patients had at least 1 NI. All severe NIs were detected during the postoperative hospital stay. Respiratory and gastrointestinal infections were common and often led to rehospitalization, thus increasing costs.

Predictive value of paediatric risk of mortality score and risk adjustment for congenital heart surgery score after paediatric open-heart surgery

This study compared the performance of risk adjustment for congenital heart surgery (RACHS-1) score with paediatric risk of mortality (PRISM) score in operative risk prediction after open-heart surgery in children. This was a retrospective analysis of a non-selected patient population from the paediatric intensive care unit of Helsinki University Hospital. All consecutive congenital open-heart surgery patients operated in Finland between the years 2000 and 2004, who were under 18 years of age, were included in this retrospective analysis. Predicted probability of mortality was calculated using the published algorithms for RACHS-1 and PRISM. Those were compared with observed mortality at day 30 postoperatively. Of the 1001 patients, 42 patients died (4.2%) within 30 days of open-heart surgery. The discrimination power, evaluated by AUC (area under curve) for RACHS-1 was moderate: 0.74 (95% CI 0.66-0.82). The AUC-value for PRISM was poor, namely 0.66 (95% CI 0.57-0.75). Both risk scoring systems overestimated the mortality with calculated standardised mortality ratios (SMR) of 0.48 for PRISM and 0.39 for RACHS-1. With only a moderate discriminating AUC, RACHS-1 failed to adequately predict death after paediatric open-heart surgery. The predictive power of PRISM in this patient group was poor. Both scores overestimated the actual mortality rate.

Therapy Insight: orthopedic complications after solid organ transplantation in childhood

Several factors, such as immobilization, metabolic bone disease and immunosuppressive drugs, can compromise the quality of bone in children who have undergone solid organ transplantation. In contrast to adults, decreased bone mineral density has been reported in only a small proportion of pediatric transplant patients, and the relationship between low bone mineral density and fracture risk has not been established in children. Nevertheless, fractures, scoliosis, and joint and spinal degeneration are common in patients who received solid organ grafts as children. Avascular bone necrosis occurs infrequently in this patient population. Future studies should evaluate the effects of the underlying disease, transplantation and immunosuppression on the metabolism of bone and cartilage. On the basis of our own clinical experience and literature review, the growing spine of children who have received transplants should be continuously evaluated, and follow-up of bone mineral density is indicated. By contrast, routine MRI of the joints seems unnecessary.

Risk of Surgery for Congenital Heart Disease in the Adult: A Multicentered European Study

BACKGROUND

Surgery for congenital heart disease (CHD) has changed considerably during the last three decades. The results of primary repair have steadily improved, to allow treating almost all patients within the pediatric age; nonetheless an increasing population of adult patients requires surgical treatment. The objective of this study is to present the early surgical results of patients who require surgery for CHD in the adult population within a multicentered European study population.

METHODS

Data relative to the hospital course of 2,012 adult patients (age > or = 18 years) who required surgical treatment for CHD from January 1, 1997 through December 31, 2004 were reviewed. Nineteen cardiothoracic centers from 13 European countries contributed to the data collection.

RESULTS

Mean age at surgery was 34.4 +/- 14.53 years. Most of the operations were corrective procedures (1,509 patients, 75%), followed by reoperations (464 patients, 23.1%) and palliative procedures (39 patients, 1.9%). Six hundred forty-nine patients (32.2%) required surgical closure of an isolated ostium secundum atrial septal defect. Overall hospital mortality was 2%. Preoperative cyanosis, arrhythmias, and NYHA class III-IV, proved significant risk factors for hospital mortality. Follow-up data were available in 1,342 of 1,972 patients (68%) who were discharged home. Late deaths occurred in 6 patients (0.5%). Overall survival probability was 97% at 60 months, which is higher for corrective procedures (98.2%) if compared with reoperations (94.1%) and palliations (86.1%).

CONCLUSIONS

Surgical treatment of CHD in adult patients, in specialized cardiac units, proved quite safe, beneficial, and low-risk.

Associations of body size at birth with late-life cortisol concentrations and glucose tolerance are modified by haplotypes of the glucocorticoid receptor gene

CONTEXT

Small body size at birth is associated with cardiovascular disease and type 2 diabetes in adult life. This link may be in part mediated by early-life programming of the hypothalamic-pituitary-adrenal axis (HPAA) function.

OBJECTIVE

Our objective was to assess whether haplotypes of the glucocorticoid receptor (GR) gene modify this link.

DESIGN AND PARTICIPANTS

We conducted a birth cohort study that included 437 men and women born in Helsinki, Finland, during 1924-1933, whose birth measurements were recorded.

MAIN OUTCOME MEASURES

We studied how the oral glucose tolerance test and fasting plasma total and free cortisol concentrations and, in a subset of 162 women, a more detailed HPAA evaluation, are predicted by body size at birth and haplotypes of the GR locus. We also measured the haplotype-specific relative mRNA expression level for the haplotype of interest.

RESULTS

One of the haplotypes was associated with lower birth weight and length and higher fasting plasma and mean 24-h salivary cortisol. Moreover, this haplotype modified the association of length at birth with adult phenotypes; in carriers, short length at birth was associated with increased fasting plasma cortisol, cortisol/corticosteroid-binding globulin ratio, impaired glucose tolerance or diabetes [1 cm decrease corresponded to 1.36-fold odds ratio; 95% confidence interval (CI), 1.09-1.70; P = 0.007], and higher 120-min glucose (5.8%; 95% CI, 2.5-9.1%; P = 0.0007), but no association was seen in noncarriers (P for interaction was 0.06, 0.01, 0.02, and 0.01, respectively). The mRNA expression level of this haplotype was 93.7% (95% CI, 90.5-96.8%; P = 2.2 x 10(-4)) of the expression level of the other haplotypes.

CONCLUSIONS

A common GR haplotype may contribute to and modify the association of short length at birth with adult glucose tolerance and HPAA function by a mechanism that affects regulation of GR expression.

Spine after solid organ transplantation in childhood: a clinical, radiographic, and magnetic resonance imaging analysis of 40 patients

STUDY DESIGN

A cross-sectional study of the spine in 40 young adults after solid organ transplantation in childhood.

OBJECTIVE

To evaluate the impact of organ transplantation and long-term immunosuppressive treatment on growing spine using magnetic resonance imaging (MRI).

SUMMARY OF BACKGROUND DATA

A review of the current literature reveals no systematic evaluation of the spine after transplantation in childhood.

METHODS

A total of 40 adult patients (mean age 22.1 years, range, 16.0-27.0), who received either kidney, liver, or heart transplant as children, were evaluated. Mean follow-up after transplantation was 11.2 years (range 3.0-18.0). All patients filled in a questionnaire, underwent an interview and physical examination, as well as had MRI of the spine. Standing spinal radiographs were taken from patients with a rib hump > or = 6 degrees.

RESULTS

There were 8 (20%) patients who had a history of vertebral fracture. Eleven (28%) patients reported frequent back pain at rest. There were 15 (38%) patients who had scoliosis > 10 degrees (range 10 degrees -69 degrees ). On MRI, narrowed disc spaces were noted in 32 (80%) patients, and irregular endplates were noted in 24 (60%). There were 14 (35%) patients who had at least 1 compressed or wedged vertebra (> 20%). Patients treated for acute rejection had wedged vertebrae, speckled or black disc spaces, and irregular endplates more often than patients without rejections. Males had wedged vertebrae more often than females (P = 0.0067).

CONCLUSIONS

Back pain, scoliosis, wedged vertebrae, and narrowed, degenerated disc spaces are common after solid organ transplantation in childhood.

The arterial switch operation in Europe for transposition of the great arteries: a multi-institutional study from the European Congenital Heart Surgeons Association

OBJECTIVES

This study analyzes the results of the arterial switch operation for transposition of the great arteries in member institutions of the European Congenital Heart Surgeons Association.

METHODS

The records of 613 patients who underwent primary arterial switch operations in each of 19 participating institutions in the period from January 1998 through December 2000 were reviewed retrospectively.

RESULTS

A ventricular septal defect was present in 186 (30%) patients. Coronary anatomy was type A in 69% of the patients, and aortic arch pathology was present in 20% of patients with ventricular septal defect. Rashkind septostomy was performed in 75% of the patients, and 69% received prostaglandin. There were 37 hospital deaths (operative mortality, 6%), 13 (3%) for patients with an intact ventricular septum and 24 (13%) for those with a ventricular septal defect (P < .001). In 36% delayed sternal closure was performed, 8% required peritoneal dialysis, and 2% required mechanical circulatory support. Median ventilation time was 58 hours, and intensive care and hospital stay were 6 and 14 days, respectively. Although of various preoperative risk factors the presence of a ventricular septal defect, arch pathology, and coronary anomalies were univariate predictors of operative mortality, only the presence of a ventricular septal defect approached statistical significance (P = .06) on multivariable analysis. Of various operative parameters, aortic crossclamp time and delayed sternal closure were also univariate predictors; however, only the latter was an independent statistically significant predictor of death.

CONCLUSIONS

Results of the procedure in European centers are compatible with those in the literature. The presence of a ventricular septal defect is the clinically most important preoperative risk factor for operative death, approaching statistical significance on multivariable analysis.

Comparison of direct and intravesical measurement of intraabdominal pressure in children

PURPOSE

The aim of this study was to compare directly measured intraabdominal pressure with the pressure measured indirectly via urinary catheter using different bladder-filling volumes in children.

METHODS

Prospective observational study in pediatric intensive care unit at a university children's hospital. Three simultaneous measurements of intraabdominal pressure were performed in 14 children, mean age 1.6 months (range, 0.2-56), after cardiac surgery requiring cardiopulmonary bypass directly via an intraperitoneal dialysis catheter and indirectly via indwelling urinary catheter with bladder volumes of 1, 1.5, 2, 2.5, and 3 mL/kg of physiological saline. Of the 14 patients, 9 were mechanically ventilated at the time of the intraabdominal pressure measurements.

RESULTS

Directly measured intraabdominal pressure ranged between 0 and 10 mm Hg and showed the highest correlation (r = 0.971, P < .0001) with the pressure measured via urinary catheter using bladder-filling volume of 1 mL/kg. The higher the bladder-filling volume, the higher was the overestimation of the intraabdominal pressure and the weaker was the correlation with the direct measurement. Overestimation of intraabdominal pressure was 1.3, 2.0, and 2.9 mm Hg, with bladder volume of 1, 2, and 3 mL/kg, respectively.

CONCLUSION

These data suggest that intravesical pressure closely correlates with intraabdominal pressure in children. A bladder-filling volume of 1 mL/kg is recommended for the measurement of intraabdominal pressure in children with a risk of abdominal compartment syndrome.

Results of surgery for Ebstein anomaly: A multicenter study from the European Congenital Heart Surgeons Association

OBJECTIVE

Since most centers' experience with Ebstein anomaly is limited, we sought to analyze the collective experience of participating institutions of the European Congenital Heart Surgeons Association with surgery for this rare malformation.

METHODS

The records of all 150 patients (median age 6.4 years) who underwent surgery for Ebstein anomaly in the 13 participating Association centers between January 1992 and January 2005 were reviewed retrospectively. Patients with congenitally corrected transposition were excluded.

RESULTS

Most patients (81%) had Ebstein disease type B or C and significant functional impairment (61% in New York Heart Association class III or IV) and 16% had prior operations. Surgical procedures (n = 179) included valve replacement (n = 60, 33.5%), valve repair (n = 49, 27.3%), 1(1/2) ventricle repair (n = 46, 25.6%), palliative shunt (n = 13, 7.26%), and other complex procedures (n = 11, 6.14%). There were 20 hospital deaths (operative mortality 13.3%) after valve replacement in 5 patients, valve repair in 3, 1(1/2) ventricle repair in 7, palliative procedures in 3, and miscellaneous procedures in 2. Younger age and palliative procedures were univariate risk factors for operative death, but only age was an independent predictor on multivariable analysis.

CONCLUSIONS

Most patients coming to surgery presented in childhood and were significantly symptomatic. More than half underwent valve replacement or repair, but a considerable proportion had severe disease necessitating 1(1/2) ventricle repair or palliative procedures. Operative mortality did not differ significantly among repair, replacement, and 1(1/2) ventricle repair but was associated with palliative procedures for severe disease early in life, young age being the only independent predictor of operative death.

Avascular Bone Necrosis of the Hip Joint after Solid Organ Transplantation in Childhood: A Clinical and MRI Analysis

BACKGROUND

Aseptic osteonecrosis is a well-known complication after solid organ transplantation in adults. The occurrence of osteonecrosis in growing age has been studied after kidney transplantation, but no systematic evaluation of the joints has been reported after heart or liver transplantation in childhood.

METHODS

A total of 196 children--93% of patients surviving kidney, liver and heart transplantation in Finland--participated in a cross-sectional survey. All children underwent a detailed clinical examination and filled out a questionnaire on musculoskeletal symptoms. Radiographs were taken in case of joint pain or abnormal clinical findings. In addition, magnetic resonance imaging (MRI) from the hips was taken on a random basis from 34 adult patients transplanted as a child. The mean follow-up time of all patients after transplantation was 9.2 years (range, 2.4 to 20.5 years).

RESULTS

Twenty-eight (14%) patients reported prolonged joint or limb pain without previous trauma. Specific etiology for the limb pain was not found in 10 (5.1%) patients. Osteonecrosis seen in radiographs or MRI was noted in seven (3.6%) patients, of which three had received kidney, three liver, and one heart graft. Femoral head was affected in five patients, as well as talus bilaterally in one patient and lateral femoral condyle in one patient. All patients were older than 12 years at the time of diagnosis of the osteonecrosis. MRI of the hips of 34 randomly selected patients showed only one asymptomatic necrosis of the femoral head.

CONCLUSIONS

Symptomatic osteonecrosis of the hip is uncommon after solid organ transplantation in childhood using the current immunosuppressive medications.

Coronary Sinus Orifice Atresia With Left Superior Vena Cava in Patients With Univentricular Heart

Two patients with hypoplastic left heart syndrome had coronary sinus orifice atresia with persistent left superior vena cava. Both patients underwent successfully coronary sinus unroofing. One underwent surgery at the time of the bidirectional Glenn procedure and the other before creation of a total cavopulmonary connection. According to our population-based database, 10.3% of patients with univentricular heart have persistent left superior vena cava, and 2.3% have associated coronary sinus orifice atresia. Our cases highlight the importance of recognizing this anomaly in patients with univentricular heart to avoid high coronary venous pressure, which is potentially lethal.

Normal mitral and aortic valve areas assessed by three- and two-dimensional echocardiography in 168 children and young adults

Our purpose was to investigate the effects of body size on the sizes of mitral (MV) and aortic valve (AV) areas by three-dimensional (3-D) and two-dimensional (2-D) echocardiography and to create the normal values for 3-D echocardiography. A total of 168 healthy subjects aged 2-27 years were studied by digitized 3-DE, 2-DE, and Doppler echocardiography.3-D echocardiography was performed by using rotational acquisition of planes at 18 degrees intervals from a parasternal view with electrocardiogram gating and without respiratory gating. The annular levels of MV and AV were identified from short-axis cut planes and their areas were measured by planimetry. The diameters of mitral annulus, left ventricular outflow tract (LVOT), and aortic annulus were measured by 2-DE from the apical and parasternal long-axis views. Flow indices were measured by Doppler from MV inflow and the flow in LVOT and in the ascending aorta. Both MV and AV annular areas increased linearly in relation to body size. In the total study group the estimated areas for MV were 5.2 +/- 0.9 cm2/m2 by 3-DE, 3.7 +/- 0.5 cm2/m2 by 2-DE, and 2.0 +/- 0.4 cm2/m2 by continuity equation. The respective values for AV were 2.7 +/- 0.5, 2.1 +/- 0.3, and 1.8 +/- 0.4 cm2/m2. MV velocity time integral (VTI)/ascending aorta VTI increased from 0.80 (0.26) to 0.95 (0.23) with increased body surface area (BSA), whereas MV VTI/LVOT VTI was 1.2 (0.2) in all BSA groups. MV and AV annulus areas increase linearly in relation to body size. 3-DE gives greater estimates for the areas than 2-DE and Doppler equation methods. The data obtained from 168 healthy subjects may serve as a reference for clinical use in patients with various cardiac abnormalities.

Scoliosis after solid organ transplantation in children and adolescents

The occurrence of scoliosis in children after solid organ transplantation is not known. A total of 196 children, which is 93% of patients surviving kidney, liver and heart transplantation in our country, participated in a cross-sectional survey. All children were screened for rib hump, and those with clinically significant hump (over 6 degrees ) underwent radiographs of the spine. The occurrence of scoliosis was compared to data obtained from a previously published comparison group. Forty-three (21.9%) of the patients had scoliosis greater than 10 degrees , and 21 (10.7%) of them had curves greater than 20 degrees . The RR (95% CI) for scoliosis needing treatment (over 20 degrees ) was 17.0 (6.75-42.7) in the patients as compared with control population. The occurrence of scoliosis was 17.9% of the kidney, 13.6% of the liver and 51.7% of the heart transplant patients (p < 0.001). In a logistic regression model, heart transplantation (OR (95% CI) 7.27 (2.62-20.2)) and growth hormone treatment (3.98 (1.77-8.94)) were most significant risk factors for scoliosis. The risk of scoliosis is increased in patients with solid organ transplantation. Pediatricians treating these patients should be aware of this increased risk to diagnose early curves and to refer these patients to an orthopedic surgeon.

Increased QT dispersion and loss of sinus rhythm as risk factors for late sudden death after Mustard or Senning procedures for transposition of the great arteries

Increased QT dispersion and loss of sinus rhythm were both associated with sudden cardiac death in patients with transposition of the great arteries after Mustard and Senning operations at the early and late postoperative periods. A combination of increased QT dispersion with loss of sinus rhythm increases the positive predictive value for sudden cardiac death in patients with transposition of the great arteries after Mustard and Senning procedures.

Long-term results of pediatric cardiac surgery in Finland: education, employment, marital status, and parenthood

OBJECTIVE

This population-based study was designed to examine the psychosocial outcome of Finnish patients who had been operated on for congenital heart disease during childhood.

METHODS

A questionnaire was mailed to 3789 adult patients who had been operated on for congenital heart defects in Finland. Of these, 2896 (76%) answered the questionnaire. The mean age of patients was 33 years (range: 18-59 years), and they had had their first operation 9 to 46 years earlier.

RESULTS

The patients had coped well with their defects when compared with the general Finnish population. The educational level of patients was comparable to and employment level was higher than expected (70% vs 66%, respectively). They were living in a steady relationship as often as the general population, but the number of parents among the patients was lower than that expected (47% vs 49%, respectively). The incidence of congenital heart disease among the 2697 children of the patients was 2.4%.

CONCLUSION

Our results confirm that in addition to high survival rate, the long-term psychosocial outcome of patients with surgically treated congenital heart defects is good if they do not have any additional syndromes that cause mental retardation.

Normal aortic dimensions and flow in 168 children and young adults

BACKGROUND

Knowledge of normal aortic dimensions is important while evaluating children with aortic root dilatation.

OBJECTIVE

The purpose of the study was to create normal values for aortic dimensions with two-dimensional echocardiography and for aortic flow velocities with Doppler echocardiography in healthy children and young adults.

DESIGN AND PATIENTS

One hundred and sixty-eight healthy children were studied by a single observer using digitized two-dimensional (2DE) and Doppler echocardiography.

METHODS

The 2DE measurements were obtained at the level of aortic annulus, sinus, sinotubular junction, before the origin of innominate artery, before and after the origin of left carotid artery, after left subclavian artery and descending aorta at the level of the diaphragm. Doppler measurements were made from ascending aorta and from descending aorta.

RESULTS

For the analysis the subjects were divided into five groups according to body surface area (BSA): 0.5-0.75 m2, 0.75-1.0 m2, 1.0-1.25 m2, 1.25-1.5 m2 and over 1.5 m2. Aortic dimensions normalized to BSA were greater in smaller children at all levels. All diameters correlated closely with age, BSA, height and weight (for each r>0.75, P<0.001). The best predictor of aortic dimensions was BSA with r values over 0.84 for all estimates (P<0.001). The diameters of ascending and descending aorta were similar in both genders when indexed to BSA. Flow velocities in descending aorta were greater than those measured in ascending aorta (P<0.001 for all measurements). There were significant inverse correlations with heart rate and velocity time integral in ascending and descending aorta (r=-0.32 and -0.53, P<0.001, respectively).

CONCLUSIONS

The presented aortic dimensions at eight levels from the valve annulus to the descending thoracic aorta by 2DE in conjunction with Doppler measurements of ascending and descending aorta in 168 healthy subjects will serve as reference data for further studies and clinical use in patients with various cardiac abnormalities.

Left atrial and left ventricular function in healthy children and young adults assessed by three dimensional echocardiography

OBJECTIVE

To establish normal values of left atrial and left ventricular volumes and function in children and young adults using three dimensional echocardiography (3DE).

METHODS

169 healthy subjects aged 2 to 27 years were studied by digitised 3DE. 3DE was achieved using rotational acquisition of planes at 18 degrees intervals from the parasternal view for the left atrium and from the transthoracic apical view for the left ventricle with ECG gating and without respiratory gating. Left atrial and left ventricular volumes could be calculated throughout the heart cycle, and the respective time-volume curves were reconstructed in each subject.

RESULTS

For the analysis the subjects were divided into five groups according to body surface area: 0.5-0.75 m2, 0.75-1.0 m2, 1.0-1.25 m2, 1.25-1.5 m2, and over 1.5 m2. Mean (SD) left atrial maximum volume/body surface area was 19.6 (3.5), 21.7 (3.7), 22.0 (4.7), 24.5 (4.8), and 27.4 (6.4) ml/m2; left ventricular maximum volume/body surface area was 50.1 (8.8), 54.9 (10.1), 56.4 (9.9), 58.7 (11.0), and 64.4 (10.3) ml/m2. Left atrial active emptying increased from 19% to 35% with age (r = 0.34, p < 0.001) and with decreasing heart rate (r = -0.28, p < 0.001).

CONCLUSIONS

Transthoracic 3DE is well suited for studying the phasic changes in left atrial and left ventricular volumes in young children as well as in adults. The data obtained from 169 healthy subjects will serve as a reference for further studies in patients with various cardiac abnormalities.

Serum C-reactive protein in pediatric kidney and liver transplant patients

The clinical manifestations of different complications after organ transplantation (Tx) are often vague, and simple laboratory tests for early diagnosis would be valuable. In this work we retrospectively analyzed our data on the daily measurements of serum C-reactive protein (CRP) in 132 children after 63 liver and 83 kidney Txs. A total of 3,886 CRP measurements were performed and 353 episodes of elevated CRP were recorded. One-third of these were regarded as a response to surgery. The CRP level normalized within 5-10 days post-operatively in patients who had a favorable outcome, but in patients with a poor outcome CRP tended to remain elevated. Half of the CRP elevations were associated with complications such as acute rejection, infection or thrombotic events. An elevated serum CRP level was found in 68% of the rejection episodes, in 88% of the bacterial infections, and in 73% of the viral infections. The most significant elevations were associated with bacterial infection. In nine of 11 vascular complications, an elevation of CRP was also recorded. Serum CRP responded to rejection therapy in 86% of the episodes. The initial CRP level did not predict steroid-resistant rejection. CRP seemed to be a more sensitive marker than fever or white blood cell (WBC) count in all complications. We conclude that the daily measurement of serum CRP is a simple and fairly sensitive, but non-specific, method for detecting rejection and infectious complications after pediatric liver and kidney Tx.

Postoperative nitric oxide therapy in children with congenital heart disease. Can the need be predicted?

The necessity for postoperative inhaled nitric oxide (NO) therapy and predictive factors for that need were retrospectively analysed in 457 paediatric patients at risk of pulmonary hypertensive events following open-heart surgery for congenital heart disease. Inhaled NO was given postoperatively to 46% of the study group and to 23% of all patients undergoing open-heart surgery during the study period. Factors associated with increased need for postoperative NO were age <1 year, Down's syndrome, preoperative pulmonary hypertension and increased pulmonary vascular resistance. Using a multivariate model based on these factors, 73% of the patients who were given NO were identified. Thus, in a setting with unrestricted access to NO therapy, almost half of the patients with cardiac lesions that commonly give rise to postoperative pulmonary hypertension were given postoperative NO. Seventy-three percent of postoperative NO treatment was associated with a relatively small number of pre- and perioperative patient-related risk factors.

Perioperative determinants and outcome of cardiopulmonary arrest in children after heart surgery

OBJECTIVES

To identify perioperative factors associated with postoperative cardiopulmonary arrest (CA) in the pediatric intensive care unit (PICU) in children undergoing cardiovascular surgery, and to report the outcome of cardiopulmonary resuscitation (CPR) in these patients.

METHODS

We reviewed the medical records of all patients under 16 years of age who had undergone cardiovascular surgery and sustained CA in PICU in an urban, tertiary care children's hospital over a 5-year period. We used two control groups of patients who recovered without CA. (1) Sixty-five patients, who were operated under deep hypothermic circulatory arrest (DHCA) during the study period. (2) All patients who underwent repair of congenital heart lesions without DHCA in 1994 (n=278).

RESULTS

Eighty-two children experienced CA during postoperative care in PICU, mainly from cardiovascular causes. Thirty-four (41%) were declared dead without attempted resuscitation, CPR was initiated in 48 (59%). The primary survival rate was 56% and 1 year survival rate was 19%. The incidence of CA was 3.6% for closed heart operations, 4.9% for intra-cardiac surgery without DHCA, and 27% for operations involving DHCA. Thirty-three per cent of patients with CA arrested during the first 24 postoperative h. Preoperative mechanical ventilation (P=0.03), prostaglandin E1 (P=0.001) and inotropic support (P=0.04) were given significantly more frequently to patients who postoperatively required CPR, compared to control groups. Patients in whom CPR was attempted were younger than the 1994 controls (0.4 vs. 1.2 years; P<0.04), had longer mean aortic-cross-clamp times (76 vs. 51 min; P<0.0001) and cardiopulmonary bypass times (124 vs. 85 min; P<0.0002), and required more inotropic support upon leaving the operating room (P<0.0001). Patients who received CPR had significantly longer DHCA times (53 vs. 32 min; P<0.0002) and required more inotropic support than patients in the DHCA control group (P<0.002).

CONCLUSIONS

CA after pediatric cardiac surgery is associated with repair of complex congenital heart anomalies in patients who require preoperative mechanical ventilation and vasoactive agents, prolonged aortic cross-clamp, circulatory arrest; and heavy postoperative inotropic support.

Amrinone versus dopamine and nitroglycerin in neonates after arterial switch operation for transposition of the great arteries

OBJECTIVE

To compare the efficacy and safety of amrinone and a combination of dopamine and nitroglycerin in neonates after reconstructive surgery for transposition of the great arteries.

DESIGN

A prospective, randomized, double-blind study.

SETTING

Pediatric intensive care unit in a university hospital.

PARTICIPANTS

Thirty-five neonates with transposition of the great arteries.

INTERVENTIONS

A loading dose of amrinone, 2 mg/kg, followed by a maintenance infusion of 7.5 microg/kg/min, were administered to 16 neonates before separation from cardiopulmonary bypass. The remaining 19 patients were administered a combination of dopamine, 5 microg/kg/min, and nitroglycerin, 1 microg/kg/min. An open-label epinephrine infusion was administered in both groups as required.

MEASUREMENTS AND MAIN RESULTS

The circulatory state of the patients was evaluated from 4 to 18 hours after cardiopulmonary bypass. The systemic blood flow index, calculated using the Fick principle, was higher in the amrinone group (1.7+/-0.5 L/min/m2 [mean +/- SD]) compared with the dopamine-nitroglycerin group (1.4+/-0.4 L/min/m2; p < 0.04). The systemic vascular resistance in the amrinone group was lower (26+/-8 Wood units x m2) than in the dopamine-nitroglycerin group (35+/-12 Wood units x m2; p < 0.02). The oxygen extraction ratio was higher in the dopamine-nitroglycerin group (0.34+/-0.08) compared with the amrinone group (0.28+/-0.06; p < 0.02). Lower platelet counts were observed in the amrinone group, but no difference in hemorrhagic complications was seen between the groups.

CONCLUSION

With the dosage regimen used, supplemented with epinephrine, amrinone provides a higher cardiac output and more favorable oxygen dynamics than a combination of dopamine and nitroglycerin.

Long-term follow up of renal function and histology after renal allograft transplantation in early childhood

Survival rates, renal function, and histopathology were evaluated in 49 prospectively followed patients transplanted under 5 years of age at our center. Most patients (84%) suffered from congenital nephrosis of the Finnish type. Triple immunosuppression with cyclosporine administered in three daily doses to pre-school children was used. Patient survival 7 years after transplantation was 98% and graft survival 88%. All graft losses were due to post-transplantation nephrosis. The proportion of pathological findings in the follow-up biopsies did not change substantially with time. Five years after transplantation, 47% showed a normal histology and after 7 years this rose to 67%. Mean glomerular filtration rate (GFR) was 68 and 55 ml min per 1.73 m2 5 years and 7 years, respectively, after transplantation. The decline in GFR with time was significant. We conclude that good long-term results can be achieved with individually tailored triple immunosuppression in the youngest age group, even with cadaveric donors.

Paediatric kidney transplantation

Renal transplantation is the optimal form of renal replacement therapy leading to substantial improvement in the quality of life. It has rapidly become the standard treatment for end-stage renal disease in children. However, despite impressive short-term results significant long-term problems remain unsolved. Because of the lack of effective treatment for chronic rejection and common recipient noncompliance, allograft half-life has not improved significantly during the last decade. A paediatric recipient is likely to need several retransplantations in adulthood. Moreover, the immunosuppressive drugs used today have potentially serious side-effects including nephrotoxicity and de novo malignancy. These are especially relevant for paediatric recipients who will continue to receive therapy for several decades. Most therapeutic protocols used for children are derived from those used for adults. However, the metabolic differences between an adult and a growing and developing paediatric transplant recipient are not always adequately appreciated before these new therapies are initiated. In the near future, we are likely to see new and more efficient drugs become available. It is important that we try to understand their properties in children and use them and our current arsenal on an individual basis aiming at optimal graft survival but also at avoiding unnecessary adverse effects.

Kidney function in cyclosporine-treated pediatric heart transplant recipients

BACKGROUND

End-stage kidney disease may develop in 1% to 3% of cyclosporine-treated heart transplant recipients, and most patients show a decreased glomerular filtration rate. There are little data on kidney function in pediatric recipients, although good function is needed for their optimal development.

METHODS

Kidney function was prospectively investigated in 10 children receiving triple immunosuppression (cyclosporine, azathioprine, methylprednisolone) during the first 18 months after heart transplantation. The early cyclosporine trough level target was 300 to 500 micrograms/L and 100 to 200 micrograms/L after the first year. 51Chromium-ethylenediamine tetraacetic acid, para-amino hippuric acid, lithium, and sodium clearances, measurements of serum and urinary electrolytes, and urinary concentration tests were performed. Renal biopsy specimens were obtained from four patients after 18 months.

RESULTS

Heart function was good in all patients. Six patients (60%) remained rejection-free at 18 months. The mean glomerular filtration rate was 92.4 ml/min/1.73 m2 before transplantation, increased to 115 by 6 months (p < 0.05), and thereafter remained stable. The mean renal plasma flow was 487 ml/min/1.73 m2 after 18 months. Hypertension was seen in all patients at discharge but in only one at 18 months. Mild hyperuricemia was the most common sign of tubular dysfunction occurring in five patients at discharge but in only two patients at 18 months. The result of kidney histopathologic study was normal in three of four patients, and cyclosporine nephrotoxicity was not diagnosed.

CONCLUSIONS

Triple immunosuppression with cyclosporine adequately protects the graft against acute rejection. It is compatible with normal glomerular function and leads to only minor tubular disturbances.

Amrinone versus dopamine-nitroglycerin after reconstructive surgery for complete atrioventricular septal defect

OBJECTIVES

To compare the effectiveness and safety of amrinone and a combination of dopamine and nitroglycerin in infants after reconstructive surgery for congenital heart disease.

DESIGN

A prospective, randomized, double-blind study.

SETTING

Pediatric intensive care unit in a university hospital.

PARTICIPANTS

Thirty-two infants with complete atrioventricular septal defect.

INTERVENTIONS

Amrinone loading dose, 2 mg/kg, followed by a maintenance infusion, 7.5 micrograms/kg/min, was given to 17 infants before separation from cardiopulmonary bypass. The remaining 15 patients received a combination of dopamine, 5 micrograms/kg/min, and nitroglycerin, 1 microgram/kg/min.

MEASUREMENTS AND MAIN RESULTS

The circulatory state of the patients was evaluated from 4 to 18 hours after cardiopulmonary bypass. The systemic blood flow index, calculated using the Fick principle, was higher in the amrinone group (2.5 +/- 0.7 L/min/m2) compared with the dopamine-nitroglycerin group (2.0 +/- 0.6 L/min/m2, mean +/- SD). The pulmonary blood flow index in the amrinone group was higher (2.9 +/- 0.6 L/min/m2) than in the dopamine-nitroglycerin group (2.2 +/- 0.6 L/min/m2); no significant difference was noted in the mean pulmonary artery pressure. The oxygen extraction ratio was higher in the dopamine-nitroglycerin group (0.41 +/- 0.07) compared with the amrinone group (0.34 +/- 0.08). Despite lower platelet counts in the amrinone group, no hemorrhagic complications were seen in any patient.

CONCLUSIONS

With this dosage regimen, amrinone provides a higher cardiac output, more favorable oxygen dynamics, and lower pulmonary vascular resistance than dopamine and nitroglycerin.