Left bundle branch pacing after transcatheter aortic valve implantation. Initial experience of a center

Introduction

Permanent pacing is often needed in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) due to new onset conduction disorders. Nevertheless, continuous right ventricular pacing may deteriorate left ventricular ejection fraction (LVEF) and lead to poor outcomes. Thus, in last years, more physiological forms of pacing, such as left bundle branch pacing (LBBP) have been developed to prevent pacing induced cardiomyopathy.

Purpose

The aim of our study is to describe the initial experience in our center, evaluate the safety and feasibility of LBBP after TAVI and describe electrophysiological outcomes in the first months of follow-up.

Methods

We designed a prospective registry that collected all patients from the TAVI program of our center who developed conduction abnormalities in the immediate postoperative and received LBBP. We analyzed baseline characteristics, complications and procedure time, electrophysiological parameters after the procedure and final QRS interval. During follow-up LVEF, electrophysiological parameters and adverse clinical events (readmissions for heart failure, cardiovascular mortality and all-cause of mortality) were also evaluated at 3rd, 6th and 12th month.

Results

Between January 2020 and January 2022, twenty patients who developed conduction abnormalities after TAVI underwent LBBP. Seven patients (35%) had a complete atrioventricular block, two patients (10%) alternating bundle branch block and 11 (55%) had a new left bundle branch block. HV electrophysiology study was performed in 8 patients, with a median value of 68ms (66–72).

Of the 20 patients, 3 out of 4 patients were male and had history of hypertension. 40% had previous ischemic heart disease and one patient had transthyretin cardiac amyloidosis. Median age was 79 years-old (76–83.5). Balloon-expandable prosthesis was implanted in 11 patients while 9 received a self-expandable prosthesis. Median basal LVEF was 59% (41.5–60) and median NTproBNP was 1722pg/ml (535–5848).

LBBP was successful in all of the 20 patients. The median time of the procedure was 60 minutes (45–80) without suffering any complications. The median QRS interval before the procedure was 155ms (140–158) and 116ms (105–125) post-implant.

To date, two patients have died of non-cardiac cause 3 and 8 months after LBBP. There have been no readmissions for heart failure. LVEF (pre and post-LBBP) and electrophysiological parameters post-implant and three-month follow-up are shown in Table 1.

Conclusions

In our experience, LBBP after TAVI is a safe and feasible procedure. Despite the small sample size and short follow-up period, our first results indicate stability of LVEF and pacemaker parameters.

Funding Acknowledgement

Type of funding sources: None.

Past and future of HIV infection. A document based on expert opinion

HIV infection is now almost 40 years old. In this time, along with the catastrophe and tragedy that it has entailed, it has also represented the capacity of modern society to take on a challenge of this magnitude and to transform an almost uniformly lethal disease into a chronic illness, compatible with a practically normal personal and relationship life. This anniversary seemed an ideal moment to pause and reflect on the future of HIV infection, the challenges that remain to be addressed and the prospects for the immediate future. This reflection has to go beyond merely technical approaches, by specialized professionals, to also address social and ethical aspects. For this reason, the Health Sciences Foundation convened a group of experts in different aspects of this disease to discuss a series of questions that seemed pertinent to all those present. Each question was presented by one of the participants and discussed by the group. The document we offer is the result of this reflection.

Right bundle branch block and male sex may help predict appropriate ICD therapies in patients with non-ischemic dilated cardiomyopathy and a prophylactic implantable cardioverter defibrillator

Background

Previous studies have shown that prophylactic implantable cardioverter-defibrillators (ICD) in patients with symptomatic severe systolic dysfunction reduce all-cause mortality. However, their benefit in patients with severe systolic dysfunction of non-ischemic origin is not so clear, and is currently under debate.

Methods/Aim

We retrospectively reviewed all consecutive patients with nonischemic dilated cardiomyopathy (NICM) who underwent prophylactic ICD implantation between 2008 and 2020 in two tertiary centers. Our main goal was to identify predictors of appropriate ICD therapies (ATP and/or shocks) in this cohort of patients.

Results

A total of 224 patients were included, median age 62.7 years, 73.7% men. During a median follow-up of 51 months, 61 patients (27.2%) required appropriate ICD intervention, 7 patients (3.1%) presented inappropriate shocks and 11 (4.9%) had device infection.

Patients that received appropriate ICD therapies, as compared to those who did not, were more frequently men (86.9% vs 68.7%, p=0.006) and were significantly younger (median age 58.7 years, IQR 53.0–64.8 vs 63.7, IQR 57.0–69.8; p=0.02). Left ventricular end diastolic volume (LV-EDV) and left ventricular end systolic volume (LV-ESV) were both significantly higher in this subgroup of patients (median LVEDV 100 ml/m2 vs 86, p=0.0106; median LVESV 72.2 ml/m2 vs 60.9, p=0.0467). A trend towards lower LVEF was also noted, but it did not reach statistical significance (26% vs 29%, p=0.077). Regarding ECG previous to implant, patients that required ICD intervention presented more frequently complete right bundle branch block (RBBB) (14.8% vs 4.3%, p=0.007). On the other hand, left bundle branch block (LBBB) was more frequent in those patients who did not receive ICD intervention during follow-up (47.2% vs 26.2%, p=0.005). Table 1 summarizes baseline characteristics and results.

In a multivariate Cox regression analysis, RBBB (HR 3.9, CI 95% 1.9–8.0, p<0.001) and male sex (HR 2.38, CI 95% 1.07–5.28, p=0.034) were identified as independent predictors of appropriate ICD therapies (Figure 2).

Conclusion

RBBB and male sex may help identify patients with NICM at high-risk of ventricular arrhythmias requiring ICD intervention.

Funding Acknowledgement

Type of funding sources: None. Baseline characteristics and resultsKaplan-Meier curves

QT interval estimation in patients with right bundle branch block using validated formulas for left bundle branch block

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Adequate measurement of the QT interval is of paramount importance in order to identify patients at higher risk for ventricular arrhythmias. Previous studies have described different methods to estimate baseline QT in patients with left bundle branch block (LBBB). However, the evidence regarding the assessment of QT interval in the setting of right bundle branch block (RBBB) is scarce. 

PURPOSE

We aimed to analyze the feasibility and accuracy of the different formulas described for LBBB in the estimation of the QT interval in RBBB. 

METHODS

We enrolled patients who underwent left sided electrophysiologic procedures. All patients were in sinus rhythm and had narrow QRS. Pacing was performed from the left atrial appendage for baseline measurements, and from the left aspect of the interventricular septum (selective capture of the left bundle was attempted) to measure RBBB QT and QRS. Pacing cycle length was 800 ms or slightly below patients´ intrinsic rhythm at both locations. Measurements were performed manually (using digital calipers) according to current recommendations and corrected using Bazett. Validated formulas for LBBB QT considered are described in table 1. 

RESULTS

50 patients (42 cryoballoon pulmonary veins isolation (PVI), 4 radiofrequency PVI, 4 concealed left accessory pathways). 70% were male. Mean age was 62 ± 11 years old. Left ventricle ejection fraction was 58 ± 10%. 66% and 60% of the patients were taking betablockers and antiarrhythmic drugs, respectively. Mean pacing cycle length was 707 ± 99 ms. Baseline measurements: QRS 95 ± 10, QT 391 ± 36, QTc 467 ± 39 ms. RBBB measurements: QRS 165 ± 21, QT 448 ± 46, QTc 531 ± 52 ms. Correlations between baseline and estimated QTc were good for all the formulas (table 1). Reliability analysis showed that both Yankelson and Wang methods had the highest intraclass correlation coefficients (ICC) when trying to estimate baseline QTc. 

CONCLUSIONS

Previously described formulas for LBBB exhibit marked differences regarding reliability in the estimation of QTc interval in the setting of RBBB. According to our results, Yankelson’s method shows the most consistent agreement when estimating baseline QTc interval in patients with RBBB. Table 1.LBBB METHODFormula to estimate baseline QTcPearson’s R correlation coefficientCI (95%)Intraclass correlation coefficientCI (95%)YankelsonQTc - QRS + 95 (m) or 88 (f)0.805(0.632-0.977)0.882(0.788-0.934)Bogossian**QT - (QRS/2)0.813(0.644-0.982)0.756(-0.127-0.919)Wang**QT - (0.86*QRS - 71)0.801(0.627-0.974)0.834(0.465-0.930)Tang-Rabkin0.945*QTcRabkin - 260.722(0.521-0.923)0.711(0.019-0.885)RautaharjuQT - 155*(60/heart rate - 1) - 0.93*(QRS - 139) - 22 (m) or - 34 (f)0.780(0.599-0.961)0.105(-0.017-0.381)**Bogossian and Wang required additional HR correction (Bazett).  Abstract Figure 1. Bland-Altman

Are there gender differences in the non-prescription of Implantable Cardioverter-Defibrillators (ICDs) in primary prevention? A single-center series

Funding Acknowledgements

Type of funding sources: None.

Introduction

Primary prevention of sudden cardiac death is the main indication for ICD implantation, mainly based on left ventricular ejection fraction (LVEF). Gender differences in the diagnosis and treatment of some cardiology conditions such as myocardial infarction have been previously established.

Purpose

We aim to analyze differences in prognostic variables that could justify gender differences in the non-prescription of an ICD for primary prevention.  

Methods

A retrospective selection of patients from our center during 2019 with ventricular systolic dysfunction (LVED ≤35% in an echocardiogram) was made. We included patients at least one month after an acute myocardial infarction and with optimal medical treatment without an ICD. Death was considered during the year 2019.

Results

 We initially selected 325 patients with ventricular dysfunction, of wich 175 fulfilled the inclusion criteria (67.4% men and 32.6% women). ICD indication was considered in 47 patients out of the 175 selected (29.7% among men and 21.1% among women, p = 0.7; 70.3% among men and 78.9% among women, p= 0.30 for non-prescription). The index left ventricle end-diastolic volume (iLVEDV) was significantly worse in males. Females were older and had lower LVEF.

Conclusion

Although it is a unicenter study and we have only performed univariate comparisons, without considering confounding factors, we found no significant gender differences in prognostic variables that could justify differences in the non-prescription of an ICD for primary prevention. Results Variable Men Women p-value Age (years) 74.53 ± 0.11 79.52 ± 0.15 <0.01 Previous cancer disease 11 (13.25%) 4 (8.89%) 0.77 Cognitive impairment 12 (14.46%) 11 (24.44%) 0.08 NYHA class Mean NYHA class value I (12.05%)II (69.88%)III (18.07%)2.06 ± 0.11 I (6.67%)II (66.67%)III (26.67%)2.20 ± 0.15 0.23 Ischemic etiology 39 (46.99%) 17 (37.78) 0.84 Renal insufficiency 31 (37.35%) 21 (46.67%) 0.15 Syncope or palpitations 16 (19.28%) 8 (17.78%) 0.58 LVEDD index (cm/m2) 2.57 ± 0.11 2.71 ± 0.15 0.23 LVEDV index (ml/m2) 73.18 ± 0.11 66.84 ± 0.15 1 LVEF (%) 28.89 ± 0.11 27.17 ± 0.15 1 Death 17 (20.48%) 8 (17.78%) 0.64 Renal insufficiency: estimated glomerular filtration rate less than 30 ml/min/1,73m2 or dialysis. LVEDD: left ventricle end-diastolic diameter. NYHA: New York Heart Association.

Brain activity in well-controlled perinatally HIV-infected young adults: a fMRI pilot study

INTRODUCTION AND AIM

Perinatal transmission of human immunodeficiency virus (PHIV) is considered a chronic disease that has highlighted several cognitive deficits. From birth to early adulthood, cognition is known to play a fundamental role. However, although neurocognitive processes associated with PHIV have been extensively described by psychometric testing, data is scarce on neural activity from functional magnetic resonance imaging (fMRI) which provides in vivo physiological information.

SUBJECTS AND METHODS

We studied described impaired cognitive processes using fMRI on a group of PHIV adolescents with good immunovirological indications and healthy matched controls. Psychological status and neurocognitive functions were also assessed.

RESULTS

There were no significant differences between HIV+ and HIV- groups, either on neurocognitive testing nor in fMRI activity for phonological fluency tasks. Prolonged duration of cART was positively associated with greater brain activity in left inferior frontal gyrus (LIFG) which could indicate functional compensation.

CONCLUSIONS

These results suggest that neural activity through fMRI in PHIV adolescents with good daily functioning and good immunovirological control may be similar to their peers.

Significant differences between verbal and non-verbal intellectual scales on a perinatally HIV-infected cohort: from pediatrics to young adults

Delayed neurodevelopment is a common outcome in perinatally HIV-infected children. Our aim was to assess the intellectual profile of our cohort, considering both the infection and socio-environmental related variables. A cross-sectional cohort study was undertaken at seven major hospitals in Spain belonging to the CoRISpeS cohort (n = 97). Patients were followed up according to a standard protocol. Intellectual measures, psychosocial profile and HIV infection-related data have been analysed. The average patient age was 15 years. The median CD4 cell percentage was 35% (1,59). Viral load was undetectable in 80% of the patients and 27% were on AIDS category; 38% of whom had encephalopathy. The average composite score of both crystallized intelligence (CI) and intelligence quotient (IQ) for the cohort was lower than that of the general population (p < 0.001). Results revealed a significant difference of 38% between crystallized and fluid intelligence. There was a clear association between IQ and age of diagnosis (p = 0.022); CI and CDC classification (p = 0.035), CD4 count (p = 0.011) and CD4 nadir (p = 0.001). Higher parental education was associated with better performance across all intelligence scales (p < 0.002). A regression model showed that CI was influenced by the academic level of caregivers (p = 0.002), age at start of cART (p = 0.050) and primary language (p = 0.058). Findings revealed significant differences in verbal and non-verbal intellectual scales resulting in a misleading IQ Composite score. Crystallized intelligence demonstrated the highest level of impairment despite adequate treatment and good immunovirological status, while fluid intelligence results were average. Caregiver level of education was the strongest factor across all intelligence measures.

[Invasive fungal infections in children: similarities and differences with adults]

Invasive fungal infections (IFI) are a major cause of morbidity and mortality in immunocompromised adults and children. The purpose of this review was to update the epidemiological, clinical and therapeutic options in children, and to compare them with the adult population. Although there are important differences, the epidemiology, clinical features and risk factors for IFI have many similarities. Patient at risk include neutropenic hematology children, in whom Candida spp. y Aspergillus spp. predominate; primary immunodeficiencies, particularly chronic granulomatous disease with high susceptibility for Aspergillus spp.; and extremely premature infants, in whom C. albicans y C. parapsilosis are more prevalent. Premature babies are prone to dissemination, including the central nervous system. There are peculiarities in radiology and diagnostic biomarkers in children. In pulmonary aspergillosis, clasical signs in CT are usually absent. There is scant information on PCR and beta-D-glucan in children, and more limited on the performance of galactomannan enzyme immunoassay, that does not appear to be much different in neutropenic patients. There is a delay in the development of antifungals, limiting their use in children. Most azoles require therapeutic drug monitoring in children to optimize its safety and effectiveness. Pediatric treatment recommendations are mainly extrapolated from results of clinical trials performed in adults. There is no evidence for the benefit of preemptive therapy in children. It is necessary to foster specific pediatric studies with current and new antifungals to evaluate their pharmacokinetics, safety, and effectiveness at different ages in the pediatric population.

The incidence of AIDS-defining illnesses at a current CD4 count ≥ 200 cells/μL in the post-combination antiretroviral therapy era

BACKGROUND

Few studies consider the incidence of individual AIDS-defining illnesses (ADIs) at higher CD4 counts, relevant on a population level for monitoring and resource allocation.

METHODS

Individuals from the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) aged ≥14 years with ≥1 CD4 count of ≥200 µL between 1998 and 2010 were included. Incidence rates (per 1000 person-years of follow-up [PYFU]) were calculated for each ADI within different CD4 strata; Poisson regression, using generalized estimating equations and robust standard errors, was used to model rates of ADIs with current CD4 ≥500/µL.

RESULTS

A total of 12 135 ADIs occurred at a CD4 count of ≥200 cells/µL among 207 539 persons with 1 154 803 PYFU. Incidence rates declined from 20.5 per 1000 PYFU (95% confidence interval [CI], 20.0-21.1 per 1000 PYFU) with current CD4 200-349 cells/µL to 4.1 per 1000 PYFU (95% CI, 3.6-4.6 per 1000 PYFU) with current CD4 ≥ 1000 cells/µL. Persons with a current CD4 of 500-749 cells/µL had a significantly higher rate of ADIs (adjusted incidence rate ratio [aIRR], 1.20; 95% CI, 1.10-1.32), whereas those with a current CD4 of ≥1000 cells/µL had a similar rate (aIRR, 0.92; 95% CI, .79-1.07), compared to a current CD4 of 750-999 cells/µL. Results were consistent in persons with high or low viral load. Findings were stronger for malignant ADIs (aIRR, 1.52; 95% CI, 1.25-1.86) than for nonmalignant ADIs (aIRR, 1.12; 95% CI, 1.01-1.25), comparing persons with a current CD4 of 500-749 cells/µL to 750-999 cells/µL.

DISCUSSION

The incidence of ADIs was higher in individuals with a current CD4 count of 500-749 cells/µL compared to those with a CD4 count of 750-999 cells/µL, but did not decrease further at higher CD4 counts. Results were similar in patients virologically suppressed on combination antiretroviral therapy, suggesting that immune reconstitution is not complete until the CD4 increases to >750 cells/µL.

[Prevalence of resistance to antiretroviral drugs in Spain]

INTRODUCTION

The development of resistance to antiretroviral therapy (ART) reduces the effectiveness of these drugs in HIV-infected children.

METHODS

We performed a cross-sectional study in 86 vertically HIV-infected children, divided into four groups according to prior treatment: group 1: nucleoside reverse transcriptase inhibitor (NRTI), group 2: NRTI and non-nucleoside reverse transcriptase inhibitor (NNRTI), group 3: NRTI and protease inhibitor (PI), group 4: NRTI, NNRTI and PI.

RESULTS

In group 1 (11 children), the median treatment duration was 35 months (26 to 108). Nucleoside-associated mutations (NAMs) were found in 10 of these patients and the Q151M multiresistance mutation was found in two. The three children in group 2 were treated for 9, 32 and 42 months with NRTI and NNRTI. One child showed three NAMs and another showed Q151M. Two children had the K103N mutation. Group 3 (36 children) received treatment with NRTI and PI for 48.0 +/- 27.6 and 23.0 +/- 14.6 months, respectively. NAMs were observed in 94 % of the patients in this group, and one child showed the Q151M mutation. In group 4 (36 children) total treatment duration was 70.0 +/- 36.1 months (13.0 +/- 12.1 months with NNRTI, and 39.0 +/- 14.3 months with PI). NAMs were observed in all patients in this group, and Q151M was found in three children. K103N and Y181C were detected in 24 (67%) and 10 (28%) of the children respectively, while 32 (90%) showed primary mutations to PI.

CONCLUSIONS

A high prevalence of resistance mutations to NRTI and early appearance of resistance to NNRTI were observed in treated children.

Recommendations from SPNS/GEAM/SENBA/SENPE/AEDN/SEDCA/GESIDA on nutrition in the HIV-infected patient

OBJECTIVE

to make recommendations on the approach to nutritional problems (malnutrition, cachexia, micronutrient deficiency, obesity, lipodystrophy) affecting HIV-infected patients.

METHODS

these recommendations have been agreed upon by a group of expertes in the nutrition and care of HIV-infected patients, on behalf of the different groups involved in drafting them. Therefore, the latest advances in pathophysiology, epidemiology, and clinical care presented in studies published in medical journals or at scientific meetings were evaluated.

RESULTS

there is no single method of evaluating nutrition, and diferent techniques--CT, MRI, and DXA--must be combined. The energy requirements of symptomatic patients increase by 20-30%. There is no evidence to support the increase in protein or fat intake. Micronutrient supplementation in only necessary in special circumstances (vitamin A in children and pregnant woman). Aerobic and resistance excercise is beneficial both for cardiovascular health and for improving lean mass and muscular strength. It is important to follow the rules of food safety at every stage in the chain. Therapeutic intervention in anorexia and cachexia must be tailored, by combining nutritional and pharmacological support (appetite stimulants, anabolic steroids, and, in some cases, testosterone). Artificial nutrition (oral supplementation, enteral or parenteral nutrition) is safe and efficacious, and improves nutritional status and response to therapy. In children, nutritional recommendations must be made early, and are a necessary component of therapy.

CONCLUSION

appropriate nutritional evaluation and relevant therapeutic action are an essential part of the care of HIV-infected patients.

Dynamics of progression markers in a non-study population of human immunodeficiency virus-1 vertically infected infants with different antiretroviral treatments

Treatment with highly active antiretroviral therapy (HAART) has been shown to modify viral replication dynamics and lead to a significant recovery of CD4+ T-cells. A retrospective multicentre observational study was performed in a non-study population of 151 HIV-1-infected children, categorized into four groups according to therapy: untreated (NT), on monotherapy (MT) with a nucleoside inhibitor, on combination therapy (CT) with two nucleoside inhibitors, and on HAART, protease inhibitor containing regimens, to assess the "real-life" effectiveness of these different therapies on plasma viral load (VL) and CD4+ T-cells. VL was quantified using a standard molecular assay. CD4+ and CD8+ T-cells subsets were determined by flow cytometry. The HAART group showed the highest relative proportion (RP) of increases in 5, 10, 15 and 20% of CD4+ T-cells over baseline, and the earliest fall-off of VL (0.5, 1, 1.5 and 2 log10 copies ml-1). The RP of the fall-off of 0.5, 1, 1.5 and 2 log10 VL below baseline was 3-fold higher in HAART group than in the MT and CT groups. However, no differences were found among the groups of treated children in reaching undetectable VL.

CONCLUSION

A better evolution of VL and CD4+ T-cells was evident in children on HAART, indicating a positive effect on the immune system and clinical status, inhibiting HIV-1 replication and enabling the recovery of CD4+ T-cell counts.

Impact of antiretroviral protocols on dynamics of AIDS progression markers

AIMS

To assess the "real life" effectiveness of different antiretroviral therapies (ART).

METHODS

A retrospective multicentre observational study in 150 HIV-1 vertically infected children on the progression to AIDS (study A), and in 61 HIV-1 infected children on the evolution of the most relevant markers of progression (study B). All children were categorised into four groups: untreated (NT); on monotherapy (MT); on combination therapy (dual-ART); and on potent ART (HAART).

RESULTS

No child in the HAART group progressed to AIDS, whereas 14 children in the NT and seven in the MT groups progressed to AIDS, respectively, the differences being statistically significant. There was a mean increase of 8 units of %CD4+ per year; this was greater in the HAART group than in the other groups. The mean decrease in viral load was 0.65 log(10) copies/ml per year; this was greater in the HAART group than in the NT and MT groups. The HAART group had the lowest probability of returning to baseline %CD4+ and viral load.

CONCLUSION

Potent ART had the greatest protective effect against progression to AIDS in this observational study.

[Prognostic markers of progression to AIDS in infants vertically infected by human immunodeficiency virus type-1]

BACKGROUND

To study the prognostic AIDS progression value of the percentage of CD4+, CD8+, and plasma viral load (VL) (copies/ml) in HIV-1-vertically infected children.

PATIENTS AND METHOD

We study a cohort of 115 HIV-1 infected children older than 12 months of age. The VL was quantified using standard molecular assay. CD4 and CD8 T lymphocytes were determined by flow cytometry.

RESULTS

The children with a median of VL > 4.5 log10 (p < 0.001) and percentage of CD8+ < 25% (p = 0.05) during follow-up, progressed faster to AIDS than children with a median of VL < 4.5 log10 and CD8 > 25%. The relative risk (RR) of AIDS progression was 7-fold higher in children with median VL above 4.5 log10. When considering VL as a continuous variable, risk of progression to AIDS is 3.5-fold higher for each increase of one log10 of VL. The percentage of CD8+ T-cells had a RR of AIDS progression of 0.95/% CD8+ at entry to the study and of 0. 19/% CD8+ during follow-up, indicating protection against progression to AIDS.

CONCLUSIONS

Our results indicate that each basal values at entry in the study and during the follow-up of the percentage of CD8+ and VL helps to determine the risk of AIDS progression in HIV-1-infected children. More interestingly, the use of the two predictive markers together had higher predictive value.

Absence of maternal-fetal transmission of human immunodeficiency virus type 1 to second-trimester fetuses

OBJECTIVE

The aim of this study was to evaluate the contribution of in utero infection to the vertical transmission of human immunodeficiency virus type 1 during the second trimester.

STUDY DESIGN

We examined fetal tissues from 21 second-trimester prostaglandin-induced abortions among human immunodeficiency virus type 1-infected women and compared the fetal vertical transmission rates with those among children born to human immunodeficiency virus-seropositive women. The presence of human immunodeficiency virus type 1 nucleic acid sequences was investigated with two different highly sensitive polymerase chain reaction techniques in tissue samples from the fetal thymus, lung, and brain.

RESULTS

No human immunodeficiency virus type 1 deoxyribonucleic acid was detected in any of the samples.

CONCLUSION

The absence of human immunodeficiency virus type 1 in all fetuses in our study is compatible with a low rate of maternal-fetal transmission during the second trimester of pregnancy.

[Safety of liposomal amphotericin B in patients with high risk of nephrotoxicity]

BACKGROUND

Amphotericin B is the medication of choice in systemic or invasive fungal infections, but its use often is limited by nephrotoxicity. Lipid formulations of amphotericin B have reduced this risk, but it is not known if these medications also prevent the deterioration of kidney function in patients with previous kidney failure or at risk of kidney failure, such as newborns and patients treated with cyclosporine A.

METHOD

A retrospective analysis was made of epidemiological, clinical and analytic data collected from the clinical histories of patients with previous renal failure or at high risk of nephrotoxicity who were treated with liposomal amphotericin B at our hospital between January 1991 and January 1997.

RESULTS

An analysis was made of 23 patients (15 men and 8 women, mean age 38 years) who met established criteria. All had severe immunosuppression. Twelve patients had been treated previously with conventional amphotericin B, but treatment was interrupted for kidney failure. The other 11 patients in the group received cyclosporine A (9 cases) or were at risk of nephrotoxicity because of their underlying disease or situation (2 cases). No deterioration of kidney function due to liposomal amphotericin B was observed in any patient. In 5 of the 12 patients who had deterioration of kidney function as a result of previous use of conventional amphotericin B and lived more than one week after changing treatment, it was observed that kidney function recovered and baseline creatinine levels were reached.

CONCLUSIONS

Our findings suggest that liposomal amphotericin B can be used safely in immunocompromised patients with fungal infection who have failure or high risk of kidney failure.

B cell non-Hodgkin's lymphoma in a girl with the DiGeorge anomaly

The DiGeorge anomaly (DGA) is occasionally associated with cellular immunodeficiency. We report a female infant diagnosed with complete DGA, who developed fatal, high grade, non-Hodgkin's lymphoma that expressed Epstein-Barr virus (EBV). Non-Hodgkin's lymphoma should be considered in children with DGA.

[Treatment of an infection from an intravenous cardiac stimulation lead with extracorporeal circulation]

The infection of a transvenous lead implanted for cardiac stimulation is a rare but serious complication, because it can lead to the development of septicemia, tricuspid endocarditis, recurrent pulmonary emboli or thrombus formation in right cardiac chambers. The most efficient treatment is the removal of the entire pacing system (generator and lead). We describe our experience with the removal of infected leads with the aid of cardiopulmonary bypass. Indications of this technique and its advantages and disadvantages over the percutaneous extraction methods are discussed. A review of the literature is also presented.

[Valve repair in tricuspid endocarditis in the drug addict. Apropos a case]

Valve replacement, valvulectomy and valve repair are the alternatives for the surgical treatment of intractable tricuspid valve endocarditis. We present the case of a 24-year-old, HIV-positive Caucasian female, intravenous drug addict, with intractable tricuspid valve endocarditis, that was successfully treated with tricuspid valve repair. Advantages and major drawbacks of the different techniques are discussed and the appropriate literature is reviewed.

Microsporidiosis in HIV-positive children in Madrid (Spain)

A prospective study was carried out to determine the prevalence rates of microsporidiosis and other enteroparasites in HIV-positive children in the Madrid area. HIV-positive pediatric patients from three hospitals were enrolled in the study. A total of 293 samples (158 stool and 127 urine) were collected from 83 children whose mean age was 6.3 years and had a mean CD4 count of 504.7/mm3 (range 1-2,220/mm3), 48 of whom suffered diarrhea at the time of the study. Microsporidia identification was investigated in stool and urine samples using Weber's chromotrope-based stain, IIF and PCR species-specific tests. Enteric parasites were identified in 32.5% of the children. Cryptosporidium sp. was the most common parasite encountered (14.4%), followed by Blastocytis sp. (9.6%) and Giardia duodenalis (8.4%). Microsporidia was only found in the stools of one child (1.2% of total and 2% of those with diarrhea) and Enterocytozoon bieneusi was demonstrated by PCR. The patient was 10 years old, presented non-chronic diarrhea and his CD4 count was 298/mm3. These data differ from those previously reported by us in HIV-positive adults (13.9%) in the same area, although this group showed more severely depressed CD4 lymphocyte counts than children. New epidemiological studies should be carried out to elucidate whether additional risk factors exist between these groups.

Detection of vertical transmission of human immunodeficiency virus type 1 by a commercial polymerase chain reaction assay

In a prospective study, a commercial polymerase chain reaction (PCR) system was compared with a conventional procedure, based on PCR and hybridization with a radio-labeled probe, for the detection of human immunodeficiency virus (HIV) infection in 131 blood samples from 80 children born to HIV-seropositive mothers. Twenty-three of these children were HIV infected. The sensitivity and specificity of the commercial assay as compared with the conventional PCR procedure were 100% and 95.1%, respectively. This commercial method simplifies the performance of the conventional PCR technique and can be used to detect HIV type 1 vertical transmission.

Report of a case of aggressive cytomegalovirus retinitis in an infant with AIDS

A case of aggressive cytomegalovirus retinitis is reported in an infant with acquired immunodeficiency syndrome. Intravenous treatment with ganciclovir did not control the infection. The combination of ganciclovir and foscarnet was needed to obtain a complete response.

Sepsis in children with human immunodeficiency virus infection. The Madrid HIV Pediatric Infection Collaborative Study Group

The aims of this retrospective study were to review the frequency and patterns of bacterial sepsis in children infected with human immunodeficiency virus. The charts of 233 human immunodeficiency virus-infected children cared for during a 10-year period in 4 tertiary hospitals in Madrid were reviewed. There were 43 episodes of sepsis in 31 (13%) children. Twenty of them had acquired immunodeficiency syndrome, 10 were class PA2 and 1 was class P1B. The most common organisms recovered were: nontyphoidal Salmonella, 10 cases (23%); Streptococcus pneumoniae, 9 cases (21%); Staphylococcus epidermidis, 6 cases (14%); Escherichia coli, 5 cases (12%); Enterococcus faecalis, 4 cases (9%); Campylobacter jejuni, 2 cases (5%). In 28 episodes of bacteremia there were other sites of associated infection: pneumonia, 6 cases; urinary tract infection (UTI), 5 cases; gastrointestinal disease, 4 cases; catheter-related bacteremia, 12 cases. Eight patients had more than 1 episode of bacteremia. The rate of complications was high: 6 children had septic shock; and 2 of them developed disseminated intravascular coagulation. There was 1 death directly related to sepsis.

Hepatitis B vaccination in infants of mothers infected with human immunodeficiency virus

A study was conducted to investigate the immunogenicity of a recombinant DNA hepatitis B vaccine in neonates and children of HIV-infected women. Immunization against hepatitis B consisted of three 10 micrograms doses of the vaccine administered on a 0-, 1- and 6-month schedule. The children were followed up for an average of 11 months. Of the 118 HIV-positive neonates who participated in the study, 95 lost their HIV antibodies during the follow-up period. Most (94.2%) of the latter who completed the study responded to the vaccine. Of the 23 who remained HIV-positive, 17 completed the study and 7 produced hepatitis B antibodies.

Fetal subdural hematoma: diagnosis in utero. Case report

A subdural hematoma was diagnosed antepartum in an infant by means of sonography. An elective caesarean section was performed because cephalopelvic disproportion, and later the hematoma was drained with a poor evolution due to basal ganglia and intraventricular hemorrhage. No etiological factor of bleeding was found. This is the third published case of fetal subdural hematoma diagnosed antepartum.