Fwd: Pediatric Cardiology

Pediatric Cardiology
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High blood pressure in children: The invisible dragon Sivasubramonian Sivasankaran Annals of Pediatric Cardiology 2019 12(2):73-76

Improvement of cardiopulmonary function after minimally invasive surgical repair of pectus excavatum (Nuss procedure) in children Bibhuti B Das, Michael R Recto, Thomas Yeh Annals of Pediatric Cardiology 2019 12(2):77-82 Background: Severe pectus excavatum in children may result in cardiorespiratory functional impairment; therefore, we evaluated cardiopulmonary response to exercise before and after the Nuss procedure. Methods: Twenty-four physically active pediatric patients aged 9–18 years with severe pectus excavatum (Haller index >3.25) were included in the study. Cardiopulmonary exercise testing using treadmill and modified Bruce protocol was performed before and after the Nuss procedure. Results: Maximal oxygen uptake and oxygen pulse improved by 40.6% (32 ± 13–45 ± 10 ml/kg/min; P = 0.0001) and 44.4% (9 ± 4–13 ± 5 ml/beat; P = 0.03), respectively, after surgical correction of pectus excavatum by Nuss procedure. Significant improvement in maximum voluntary ventilation and minute ventilation after Nuss procedure was also noted. Conclusions: We found that, after repair of pectus excavatum by Nuss procedure, the exercise capacity as measured by maximal oxygen consumption improved significantly primarily due to increase in oxygen pulse, an indirect measurement of stroke volume.

Modulation of plasma triglycerides concentration by sterol-based treatment in children carrying different genes Ismael San Mauro Martín, Sara Sanz Rojo, Elena Garicano Vilar, Luis Collado Yurrita, Javier Andrés Blumenfeld Olivares Annals of Pediatric Cardiology 2019 12(2):83-89 Background: Dyslipidemias have increased during the last decades in children. Aim: The objective of this study was to analyze the influence of different polymorphisms in plasma triglyceride levels of children following a dietary treatment with plant sterols. Design: A randomized, double-blind, crossover, controlled clinical trial was carried out in 26 children (16 women). Materials and Methods: Commercial milk, with 2.24 g sterols, was ingested daily during 3 weeks , and the same amount of skimmed milk without sterols, during the 3 week placebo phase. Both phases were separated by a washout period of 2 weeks. At the beginning and end of each phase, blood draws were performed. Results: Apolipoprotein A5 Ser19Trp (P = 0.002), peroxisome proliferator-activated receptor-alpha L162V (P = 0.003), APOE APOE2/3/4 (P = 0.012), and APOE APOE2,3,4 (P = 0.025) show statistically significant differences between their haplotypes in plasma triglyceride levels. Other genes did not show statistically significant differences. Conclusions: Further studies are needed to establish which genotype combinations would be the most protective against hypertriglyceridemia.

Prevalence of hypertension and prehypertension in schoolchildren from Central India Ashish Patel, Anil Bharani, Meenakshi Sharma, Anuradha Bhagwat, Neepa Ganguli, Dharampal Singh Chouhan Annals of Pediatric Cardiology 2019 12(2):90-96 Background: Epidemiological transition with increasing burden of cardiovascular risk factors is evident not only in adults but also in children. The data on the prevalence of prehypertension and hypertension in children show large regional differences in India and such data are not available from Central India. We, therefore, conducted a large cross-sectional study in Indore to determine the distribution of blood pressure (BP) and the prevalence of hypertension and prehypertension among schoolchildren. Methods: A total of 11,312 children (5305 girls, 6007 boys) aged 5–15 years, drawn from 80 government and private schools in equal proportion, were evaluated. Anthropometric measurements were obtained and BPs were measured using The Fourth Report on The Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents as reference standard. BP ≥90th to <95th percentile for given percentile of height was considered as prehypertension, whereas any BP ≥95th percentile was defined as hypertension. Multiple linear regression analysis was used to find out the determinants of hypertension in these children. Results: Prehypertension was detected in 6.9% and 6.5% and hypertension was found in 6.8% and 7.0% of boys and girls, respectively. Height and weight were found to be a significant predictor of systolic and diastolic BP among both boys and girls. Conclusions: Our results show a high prevalence of prehypertension and hypertension in Indore schoolchildren with age and height being significant determinants. This highlights the need for routine BP measurements in children by pediatricians when they treat them for intercurrent illnesses or vaccinate them. It should also be mandatory as a part of school health checkup programs to detect childhood hypertension for further counseling and therapy.

Acetaminophen in low doses for closure of the ductus arteriosus of the premature Adriana Furletti Machado Guimarães, Fátima Derlene Rocha Araújo, Zilda Maria Alves Meira, Henrique Assis Fonseca Tonelli, Guilherme Gomes Duarte, Lívia Castro Ribeiro, Gabriele Queiroz Monteiro Rezende, Sandra Regina Tolentino Castilho Annals of Pediatric Cardiology 2019 12(2):97-102 Objective: The objective of the study is to report the experience with acetaminophen in low doses as an alternative to the treatment of the ductus arteriosus of the preterm newborn. Materials and Methods: Retrospective study including preterm newborns with patent ductus arteriosus who received oral acetaminophen because treatment with indomethacin had failed or is contraindicated. A dosage consisted of a first dose of 25 mg/kg and maintenance doses of 30 mg/kg/day, for 3 to 7 days. A second cycle was administered in cases of reopening of the ductus arteriosus. The rates of ductal closure and surgery were calculated. Patients were categorized into responder and nonresponder groups for acetaminophen, and the average values of ductal diameter, weight, gestational age, and postnatal age were compared. Results: Eighty-seven preterm newborns, with a postnatal age from 3 to 27 days, with average values of ductus arteriosus equal to 2.5 ± 0.8 mm/kg, gestational age 27.2 ± 1.9 weeks, and birth weight 888.9 ± 241 g, received acetaminophen for 3 to 7 days. A second cycle was administered in 15 preterm newborns. The ductus closure rate, after one or two cycles, was 74.7%, and the recommendations for surgical closure were progressively reduced from 50% in the 1 st year to 6.2% in the past year. Lower ductal closure rate occurred in the group of newborns with the lowest average weight (P = 0.018), the highest average ductal diameter (P = 0.002), and the lowest average gestational age (P = 0.09). Postnatal age at the start of acetaminophen use was shown to be irrelevant regarding the treatment (P = 0.591). Conclusions: Acetaminophen in low doses showed to be an effective alternative for the closure of the ductus arteriosus for preterm newborns in whom treatment with indomethacin or ibuprofen failed or was contraindicated.

Atrioventricular septal defect and tetralogy of Fallot – A single tertiary center experience: A retrospective review Khaled A Alhawri, Colin J Mcmahon, Mohammed M Alrih, Yamin Alzein, Asad A Khan, Suhaib K Mohammed, Khaled S Alalwi, Kevin P Walsh, Damien P Kenny, Jonathon G McGuinness, Lars Nolke, John M Redmond Annals of Pediatric Cardiology 2019 12(2):103-109 Background: Complete atrioventricular septal defect (CAVSD) in association with tetralogy of Fallot is a rare and complex disease that makes its repair more difficult than repair of either lesion alone. We reviewed retrospectively our experience in managing this lesion. Patients and Methods: Between February 2006 and May 2017, 16 patients who underwent repair of CAVSD/tetralogy of Fallot (TOF) were reviewed retrospectively. Fifteen patients had trisomy 21. Five patients underwent primary repair while eleven patients went for staged repair in the form of right ventricular outflow tract (RVOT) stenting (n = 9) or systemic to pulmonary (S-P) surgical shunt (n = 2). RVOT stenting has replaced surgical shunt since 2012 in our center. Early presentation with cyanosis was the main determinant factor for staged versus primary repair. Results: The median age at first palliation was 46 days (range 15–99 days). The median age at total repair for both groups was 6 months (range 3–18 months); the median age for the palliated patients was 6.5 months (range 5–18 months) while the median age for primary repaired patients was 5 months (range 3–11 months). The median weight at final repair was 6.9 kg (3.7–8.2 kg). The pulmonary valve was preserved in five patients (31%), four of them had no prior palliation. Chylothorax occurred in 50% of the patients. One late mortality occurred after final repair due to sepsis. Conclusion: CAVSD/TOF can be repaired with low mortality and morbidity. The use of RVOT stent has replaced the surgical (S-P) shunt with acceptable results in our center.

A new low-cost method of virtual cardiac dissection of computed tomographic datasets Saurabh Kumar Gupta, Diane E Spicer, Robert H Anderson Annals of Pediatric Cardiology 2019 12(2):110-116 Computed tomography has an established role in the evaluation of a variety of cardiac disorders, including congenital heart diseases. The current generation of high-speed scanners produces volumetric data at low doses of radiation. The interpretation of cardiac anatomy, however, is generally limited to multiplanar assessment of two-dimensional images. The volume rendering technique provides an excellent three-dimensional demonstration of external morphology but offers little information about the intracardiac anatomy. The alternative approach of virtual cardiac dissection, which is a modification of volume rendering, on the other hand, provides crucial insights regarding the intracardiac anatomy. At present, virtual cardiac dissection requires expensive software packages. These software packages are not available in all countries, thus limiting its use in routine clinical care. We present here the details of a newly developed technique that permits virtual cardiac dissection using a personal computer and open-source software. Our technique involves no additional cost and can be achieved in the comfort of the office or operating room of the cardiologist, radiologist, or cardiac surgeon. This enhanced three-dimensional visualization of intracardiac anatomy will surely improve the understanding of the morphological details of both normal and malformed hearts. In addition, by permitting assessment in projections with which modern-day cardiologists and cardiac surgeons are conversant, it is likely to improve clinical decision-making. We illustrate here its potential utility in the morphologic assessment of the atrial septum and its deficiencies, along with malformations of the ventricular outflow tracts, including common arterial trunk.

Isolation of the left brachiocephalic artery revisited: A 52-year literature review and introduction of a novel anatomic-clinical-prognostic classification Elaheh Malakan Rad, Hamid Reza Pouraliakbar Annals of Pediatric Cardiology 2019 12(2):117-129 Isolation of the left brachiocephalic artery (ILBA) is an extremely rare anomaly of aortic arch with diverse manifestations in the neurologic system, heart, and left upper arm. This anomaly is defined as the absence of connection of the left brachiocephalic artery (LBA) to aortic arch and connection of LBA to pulmonary artery (PA) through a patent arterial duct (PAD). However, this definition is not inclusive of all cases. Not only are there inconsistencies in the definition and terminology of this aortic arch anomaly but also there is no classification for this anomaly despite its heterogeneous nature in terms of anatomy, clinical presentation and prognosis. We performed a 52-year comprehensive literature review in the period between 1966 and 2018. Our inclusion criteria were any manuscript that included a case report or case series, with confirmed diagnosis of ILBA. All quantitative data were analyzed using descriptive analysis by SPSS version 21 (IBM SPSS Statistics, USA). Results were presented as mean ± standard deviation and median. Based on the presence or absence of connection of LBA to PA and the number of sources of steal from the LBA, we classified ILBA into three types: single-steal type with no connection of LBA to PA and single source of blood flow steal from LBA through the left subclavian artery (LSCA), double-steal type with connection of LBA to PA through PAD and two sources of steal through LSCA and arterial duct (AD), and triple-steal type with bilateral PADs and therefore, three sources of blood flow steal from LBA including the LSCA and the double ADs. Patients with single-steal type have the best prognosis and present latest with symptoms of cerebrovascular insufficiency or left arm claudication. The oldest reported patient was 69 years of age with symptoms of dizziness and near syncope. No death was reported in these patients. Double-steal type is the most common type and is often associated with genetic syndromes and/or extracardiac anomalies. Triple-steal type is the rarest type with the earliest presentation and worst prognosis. The oldest reported patient was 60 days of age. All reported cases had cardiac symptoms, pulmonary overcirculation, pulmonary hypertension, and fatal outcome.

Use of the Abbott EnSite Precision three-dimensional mapping system for the placement of an atrial pacemaker lead in a patient with congenital heart disease Christian Paech, Dirk Schnappauf, Tim Gehre, Franziska Wagner, Roman Antonin Gebauer Annals of Pediatric Cardiology 2019 12(2):130-131 We report the use of the Abbott three-dimensional mapping system (EnSite Precision) for the placement of an atrial pacemaker lead in a patient after modified Fontan procedure. The mapping system was used for the identification of a promising pacing site in the complexly modified right atrium and to visualize the successful placement of an atrial lead at the same spot.

The matter of "unbalance" in right dominant atrioventricular septal defect Ignacio Lugones, María Fernanda Biancolini, Germán Lugones, Julio César Biancolini, Ana M S de Dios Annals of Pediatric Cardiology 2019 12(2):132-134 Unbalance in atrioventricular septal defect can be found in more than one anatomic level and in different degrees at each level. The definition of “unbalance” has historically been focused in comparing the dimensions of main cardiac structures, such as the atrioventricular valve and the ventricles. However, the hemodynamic aspects of unbalance need to be considered as having, at least, similar relevance. New concepts and already described parameters must be combined and understood as a whole to help the surgical decision-making process.

Alexandros Sfakianakis
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