Coxsackie B viral infection presenting with hemorrhagic pericardial effusion and pleural effusion

We report an 11-year-old female child presenting with hemorrhagic pericardial effusion causing cardiac tamponade along with moderate left ventricular dysfunction, who screened positive for Coxsackie B infection in the setting of cough, shortness of breath, and chest pain. She needed emergency pericardiocentesis. She also had massive bilateral hemorrhagic pleural effusions requiring bilateral chest drains placement. With a presumed diagnosis of acute myopericarditis, she was treated with steroids and ibuprofen. She made a full recovery without any further recurrence of pericardial or pleural effusion.

A case series of right atrial mass in neonates: a diagnostic dilemma

The diagnosis of a right atrial mass in a neonate should be treated as an emergency. There are three major differential diagnoses for a right atrial mass-thrombus, infectious vegetation, and myxoma. Embolization of the mass can result in life-threatening complications and hence timely diagnosis and treatment is vital. This case series describes the clinical course, management, and outcome of four neonates who presented with a right atrial mass.

Duct Stenting Versus Modified Blalock-Taussig Shunt in Neonates With Duct-Dependent Pulmonary Blood Flow

Background:

Infants born with cardiac abnormalities causing dependence on the arterial duct for pulmonary blood flow are often palliated with a shunt usually between the subclavian artery and either pulmonary artery. A so-called modified Blalock-Taussig shunt allows progress through early life to an age and weight at which repair or further more stable palliation can be safely achieved. Modified Blalock-Taussig shunts continue to present concern for postprocedural instability and early mortality such that other alternatives continue to be explored. Duct stenting (DS) is emerging as one such alternative with potential for greater early stability and improved survival.

Methods:

The purpose of this study was to compare postprocedural outcomes and survival to next-stage palliative or reparative surgery between patients undergoing a modified Blalock-Taussig shunt or a DS in infants with duct-dependent pulmonary blood flow. All patients undergoing cardiac surgery and congenital interventions in the United Kingdom are prospectively recruited to an externally validated national outcome audit. From this audit, participating UK centers identified infants <30 days of age undergoing either a Blalock-Taussig shunt or a DS for cardiac conditions with duct-dependent pulmonary blood flow between January 2012 and December 31, 2015. One hundred seventy-one patients underwent a modified Blalock-Taussig shunt, and in 83 patients, DS was attempted. Primary and secondary outcomes of survival and need for extracorporeal support were analyzed with multivariable logistic regression. Longer-term mortality before repair and reintervention were analyzed with Cox proportional hazards regression. All multivariable analyses accommodated a propensity score to balance patient characteristics between the groups.

Results:

There was an early (to discharge) survival advantage for infants before next-stage surgery in the DS group (odds ratio, 4.24; 95% confidence interval, 1.37–13.14; P =0.012). There was also a difference in the need for postprocedural extracorporeal support in favor of the DS group (odds ratio, 0.22; 95% confidence interval, 0.05–1.05; P =0.058). Longer-term survival outcomes showed a reduced risk of death before repair in the DS group (hazard ratio, 0.25; 95% confidence interval, 0.07–0.85; P =0.026) but a slightly increased risk of reintervention (hazard ratio, 1.50; 95% confidence interval, 0.85–2.64; P =0.165).

Conclusions:

DS is emerging as a preferred alternative to a surgical shunt for neonatal palliation with evidence for greater postprocedural stability and improved patient survival to destination surgical treatment.

Outcome after transcatheter occlusion of patent ductus arteriosus in infants less than 6 kg: A national study from United Kingdom and Ireland

OBJECTIVES

This study aimed to report our national experience with transcatheter patent ductus arteriosus (PDA) occlusion in infants weighing <6 kg.

BACKGROUND

The technique of transcatheter PDA closure has evolved in the past two decades and is increasingly used in smaller patients but data on safety and efficacy are limited.

METHODS

Patients weighing < 6 kg in whom transcatheter PDA occlusion was attempted in 13 tertiary paediatric cardiology units in the United Kingdom and Ireland were retrospectively analyzed to review the outcome and complications.

RESULTS

A total of 408 patients underwent attempted transcatheter PDA closure between January 2004 and December 2014. The mean weight at catheterization was 4.9 ± 1.0 kg and mean age was 5.7 ± 3.0 months. Successful device implantation was achieved in 374 (92%) patients without major complication and of these, complete occlusion was achieved in 356 (95%) patients at last available follow-up. Device embolization occurred in 20 cases (5%). The incidence of device related obstruction to the left pulmonary artery or aorta and access related peripheral vascular injury were low. There were no deaths related to the procedure.

CONCLUSIONS

Transcatheter closure of PDA can be accomplished in selected infants weighing <6 kg despite the manufacturer's recommended weight limit of 6 kg for most ductal occluders. The embolization rate is higher than previously reported in larger patients. Retrievability of the occluder and duct morphology needs careful consideration before deciding whether surgical ligation or transcatheter therapy is the better treatment option.

The new occlutech duct occluder: immediate results, procedural challenges, and short-term follow-up

OBJECTIVE

The aim of this study was to assess the immediate and short-term results of transcatheter closure of patent ductus arteriosus (PDA) using the Occlutech duct occluder (ODO).

BACKGROUND

The ODO is a new self-expanding nitinol device. Its body is wider at the pulmonary artery end than the aortic end. It is available in longer lengths than the Amplatzer duct occluder.

METHODS

Twenty-two ODO implants were attempted in successive children referred for transcatheter device occlusion of PDAs ≥1 mm in diameter.

RESULTS

Median patient age was 2.4 years (range, 0.7-17.5 years), median weight was 13.1 kg (range, 6.3-40 kg), and median PDA diameter was 1.9 mm (range, 1-4.3 mm). Twenty-one out of 22 patients (95%) had successful ODO implantation. One device was withdrawn before release because it did not reach the pulmonary artery end of a long duct. Median procedure time was 40 minutes (range, 26-60 minutes) and fluoroscopy time was 4.5 minutes (range, 2.7-13.3 minutes). Occlusion rates were 19/21 (90%) at the end of the procedure, 20/21 (95%) at 24-48 hours post procedure, and 21/21 (100%) on echocardiography at a median follow-up of 4 weeks (range, 2-16 weeks). There were no device-related complications. Two infants had femoral artery occlusion, successfully treated by heparinization and thrombolysis.

CONCLUSION

This first formal clinical evaluation of the ODO indicates that it is safe and effective in occluding small-to-moderate size ducts, up to a diameter of 4.3 mm. The device produced equivalent results to the Amplatzer duct occluder. Further evaluation is required to assess whether its shape and longer length make it superior for closing large and long ducts.

Effect of hyperventilation on rate corrected QT interval of children

BACKGROUND

Hyperventilation is known to cause ST segment changes and QT variability in adults, but this has not been systematically studied in children.

AIM

To investigate the effect of hyperventilation on rate corrected QT interval (QTc) in children.

METHODS AND RESULTS

25 children (male=10) with a median age of 14 (range 8.3-17.6) years were asked to hyperventilate for 1 min before exercise testing using the modified Bruce protocol. Mean QTc at rest, after hyperventilation, at peak exercise and at 1 min of recovery was 425(±31), 460(±30), 446(±38) and 420(±32) ms, respectively. Mean increase (95% CI) in QTc after hyperventilation was 35(19 to 51) ms (p<0.001), while there was minimal difference between QT interval at rest and after hyperventilation (mean QT 352(±41) vs 357(±44) ms). In six children, there were abnormalities in T wave morphology following hyperventilation. The QTc increment following hyperventilation was more pronounced in children with resting QTc <440 ms (n=14, mean increment (95% CI): 55 (33 to 78) ms) compared to children with QTc ≥440 ms (n=11, mean increment (95% CI): 9 (-4 to 22) ms) (p=0.001). QTc prolongation following hyperventilation was seen in children with both low and intermediate probability of long QT syndrome (LQTS). Peak exercise and early recovery did not cause a statistically significant change in QTc in either of these groups.

CONCLUSIONS

Hyperventilation produces repolarisation abnormalities, including prolongation of QTc and T wave abnormalities in children with low probability of LQTS. The likely mechanism is delayed adaptation of QT interval with increased heart rate. Thus, a hyperventilation episode can be misdiagnosed as LQTS, especially in an emergency department.