Bicarotid trunk: how much is "not uncommon"?

BACKGROUND: Bicarotid trunk is the most common variation of aortic arch branching patterns. Bicarotid trunk can be a decisive factor in the surgical management of congenital heart defects. Our objective was to determine the prevalence of the bicarotid trunk among pediatric patients with congenital heart defects and to identify whether there is an association between bicarotid trunk and aortic coarctation. METHODS: From a total of 4,371 pediatric cardiac catheterizations between the years 1979 and 2010, a group of 2,033 patients were selected. Prevalence of the aortic coarctation in patients with bicarotid trunk and with a normal branching pattern was determined by evaluating the catheterization reports. In addition, associated congenital defects, vascular anomalies, and genetic syndromes were also assessed. RESULTS: Of 2,033 patients in our database, 84.8% of patients had a normal branching pattern of the aortic arch and 15.2% had a bicarotid trunk. The most frequent congenital heart defects in patients with a bicarotid trunk were ventricular septal defects, valvular pulmonary stenosis, and atrial septal defect. The most common associated vascular anomaly was the aberrant right subclavian artery. Most frequent genetic syndromes were trisomy 21, Williams syndrome, and CHARGE syndrome. CONCLUSIONS: The prevalence of bicarotid trunk of 17.6% among patients with aortic coarctation and 15.2% among the entire population studied made it not at all a rare phenomenon. Because bicarotid trunk can be a risk factor for surgery, the anatomy of the aortic arch needs to be clearly depicted and described. If ultrasonography examination cannot exclude bicarotid trunk, enhanced magnetic resonance imaging or aortic arch angiography may be necessary.

Polytetrafluoroethylene-coated pacemaker leads as surgical management of contact allergy to silicone.

We have previously reported an 18-year-old girl with a congenital heart defect who developed complete heart block after one of her corrective surgeries and who needed an epicardial pacemaker implantation. She developed contact sensitivity to silicone compounds. The problem was solved by implanting a silicone-free pacemaker system utilizing silicone-free transvenous leads. The patient was readmitted 2 years later due to lead failure. As no silicone-free epicardial leads were available, we decided to use standard silicone epicardial leads and enclose the whole system in Gore-Tex material (W.L. Gore & Associates, Flagstaff, AZ). Based on our experience we would discourage the use of silicone-free transvenous pacing leads for epicardial use.

Impact of occluder device type on success of percutaneous closure of atrial septal defects--a medium-term follow-up study.

OBJECTIVE: To identify differences between various occluder types regarding thromboembolic event rates and existence of residual shunts during medium-term follow-up. METHODS: Three hundred nine consecutive patients with presumed paradoxical embolism and scheduled for percutaneous closure of patent foramen ovale or atrial septal defect between 1997 and 2006 were considered for this study. Device implantation failed in seven patients (nonstable device position), so 302 patients (46 +/- 12 years, 190 males) formed the study group using Amplatzer (n = 208), Starflex (n = 61), and Cardiastar (n = 33) occluders. Follow-up transesophageal echocardiography was performed 1, 3, and 6 months after implantation. RESULTS: Periinterventional complications occurred in two patients (cardiac arrhythmias). There were more residual shunts in the Starflex and Cardiastar group than in the Amplatzer group at 6-month follow-up (8/61 vs. 7/33 vs. 8/208, P = 0.0005). Performing logistic regression, the type of occluder device was a significant risk factor for the presence of residual shunt 6 months after implantation (P = 0.0033; Cardiastar vs. Amplatzer OR 6.346, 95% CI 1.998 - 20.156; Starflex vs. Amplatzer OR 4.369, 95% CI 1.444 - 13.222). During mean follow-up of 31 +/- 8 months 16 recurrent thromboembolic events occurred; the annual recurrence was 2.1% for combined end-point stroke, TIA, and peripheral embolism (Amplatzer: 1.3%, Starflex: 3.9%, and Cardiastar: 3.6%, P = 0.0467). The presence of an atrial septal aneurysm was the only significant risk factor (P = 0.0168, OR 3.664, 95% CI 1.263 - 10.630) for the occurrence of thromboembolic events. CONCLUSIONS: Percutaneous closure of patent foramen ovale or atrial septal defect is a safe procedure with little incidence of peri- and postprocedural complications. There is a significant difference between the Amplatzer, Cardiastar, and Starflex occluders in regard to complete closure of the defects and annual recurrence of thromboembolic events.

Low to medium WU-virus titers in young children with lower respiratory tract infections.

The WU-virus (WUV), a novel polyomavirus, has recently been recovered from respiratory tract samples. Within a study collective of children with severe lower respiratory tract disease, 3% of the patients tested WUV positive. Viral loads ranged from 5 x 10(2) copies/ml to 1 x 10(4) copies/ml. The WUV genome-positive patients did not display specific clinical or radiological characteristics to be distinguished from other respiratory tract infections.

Comparison of the 6-minute walk test with established parameters for assessment of cardiopulmonary capacity in adults with complex congenital cardiac disease.

BACKGROUND: Objective assessment of the cardiopulmonary capacity in patients with complex congenital cardiac disease often remains difficult in clinical practice. The cardiopulmonary exercise test and determination of the levels of brain natriuretic peptide in the plasma are established tests, but expensive. The 6-minute walk test is also validated, but has not often been used in patients with heart failure due to congenital heart disease, nor compared with other tests. We sought to compare its value with the results of cardiopulmonary exercise testing and measuring the levels of brain natriuretic peptide in the plasma. METHODS: We carried out a standardized 6-minute walk test in 31 patients with complex congenital cardiac disease on the same day that they underwent cardiopulmonary exercise testing and determination of levels of brain natriuretic peptide in the plasma. Of the patients, 7 had functionally univentricular hearts, 9 had transposition, 9 had tetralogy of Fallot, 3 had common arterial trunk, and 3 had pulmonary atresia with intact interventricular septum. Uptakes of oxygen at peak exercise, and at the anaerobic threshold, were determined using cardiopulmonary exercise testing, and classified as suggested by Weber. The 6-minute walk test was performed according to a standard protocol. RESULTS: There was a significant correlation between brain natriuretic peptide, oxygen uptakes at peak exercise and 6-minute walk. The correlation between the 6-minute walk test and oxygen uptakes at the anaerobic threshold, however, was not significant. CONCLUSIONS: The 6-minute walk test can be performed easily, is inexpensive, widely available, and correlates well with measurements of brain natriuretic peptide and cardiopulmonary exercise testing, even in patients with corrected or palliated congenital cardiac malformations. A cut-off value of 450 metres in the 6-minute walk test allows a semi-quantitative classification in analogy to the classification suggested by Weber for cardiopulmonary exercise testing, and to a level of brain natriuretic peptide in the plasma of less or more than 100 picograms per millilitre.

Thromboembolic complications after Fontan procedures: comparison of different therapeutic approaches.

BACKGROUND: Although patients after Fontan procedure have a high incidence of thromboembolic complications, anticoagulant therapy is not handled uniformly. We analyzed the frequency and clinical relevance of thromboembolism after Fontan procedure and compared different therapeutic approaches. METHODS: From 1986 to 1998, 101 patients (mean age, 7.3 +/- 8.1 years) underwent Fontan type procedure (modified Fontan, n = 40; total cavopulmonary connection, n = 61). In 85 of 87 survivors, transthoracic echocardiography was performed; and in 31 transesophageal echocardiography and/or angiography was performed. Mean follow-up was 5.7 +/- 3.5 years. Three groups with different anticoagulant regimen were compared: group I without medication (n = 45), group II with acetylsalicylic acid therapy (n = 14) and group III with Coumadin (n = 26). RESULTS: Thromboembolic events occurred in 13 of 85 patients (15.3%; 3.3 events/100 patient-years). Type of operation as well as other known risk factors had no influence on the rate of thromboembolism. Within the first postoperative year, seven of 13 events occurred. A second peak developed beyond 10 years of follow-up. Patients benefit significantly from Coumadin compared with those who did not receive any medication, with similar results in the entire population and the subgroup of patients with total cavopulmonary connection (log-rank, p = 0.031 and p = 0.033, respectively). With 4.2 events/100 patient-years, the cumulative event rate was substantially higher in group I than with 1.6 in group II and with 1.1 in group III. No relevant bleeding complications occurred. CONCLUSIONS: Thromboembolism is frequent after Fontan procedure with a peak during the first postoperative year and another peak beyond 10 years of follow-up. Coumadin is the most effective prophylactic therapy in preventing thromboembolism. Therefore, we suggest initial oral anticoagulation therapy in patients with Fontan type operation.