Efficacy and safety of torasemide in children with heart failure.

OBJECTIVE: To examine the efficacy and safety of torasemide in children with chronic heart failure (HF). METHODS: 102 children with chronic HF who had received oral torasemide were analysed. Of these, 62 (de novo group) were newly diagnosed as having HF and were given torasemide as a diuretic. The remaining 40 (replacement group) had been given furosemide for >3 months before the study, and furosemide was then replaced with torasemide. Clinical signs and symptoms of HF (assessed as the HF index), humoral factors and serum potassium concentrations before torasemide treatment were compared with those obtained 3-4 weeks after torasemide treatment. Patients were also monitored for adverse effects. RESULTS: In the de novo group, torasemide significantly improved the HF index with concomitant improvement in plasma brain natriuretic peptide concentration (median (interquartile range) 52 (51) vs 43 (49) pg/ml). In a randomly selected group of 25 de novo patients with ventricular septal defect, echocardiography showed that torasemide significantly improved left ventricular geometry and function. In the replacement group, brain natriuretic peptide concentrations were also significantly decreased from 50 (104) to 45 (71) pg/ml after substitution of torasemide, but the HF index showed only a tendency for improvement (p = 0.07). Torasemide also had a potassium-sparing effect (de novo group, no change in potassium concentration; replacement group, significant increase from 4.2 (0.5) to 4.3 (0.5) mEq/l), and caused a significant rise in serum aldosterone concentration, consistent with the anti-aldosterone effect of this drug. Serum concentrations of sodium and uric acid had not changed after torasemide treatment, and there were no serious adverse events that necessitated drug withdrawal. CONCLUSION: Torasemide can be safely used, and appears to be effective for treatment of HF in children. Future clinical trials are warranted to verify the present results.

Arterial haemodynamics in patients after repair of tetralogy of Fallot: influence on left ventricular after load and aortic dilatation.

BACKGROUND: Recent histological studies of the aortic wall of patients with tetralogy of Fallot (TOF) have shown massive degeneration of the tunica media of the aorta. Such changes in arterial wall structure may significantly alter arterial wall mechanical properties, and thus cause abnormal arterial haemodynamics. OBJECTIVE: To test the hypothesis that after repair of TOF, there are abnormal arterial haemodynamics which are associated with aortic dilatation and which increased after load on the left ventricle. METHODS AND RESULTS: The subjects comprised 38 patients who had undergone complete repair of TOF, and 55 control subjects. Systemic arterial haemodynamics were investigated by measuring aortic input impedance during cardiac catheterisation. The patients with TOF had significantly higher characteristic impedance (158 (43) dyne x s x cm(-5) x m(2) vs 105 (49) dyne x s x cm(-5) x m(2)) and pulse wave velocity (561 (139) cm/s vs 417 (91) cm/s) and significantly lower total peripheral arterial compliance (0.93 (0.39) ml/mm Hg/m(2) vs 1.24 (0.58) ml/mm Hg/m(2)) than the controls (for all three variables, p<0.01 vs controls), suggesting that central and peripheral arterial wall stiffness are increased after TOF repair. Additionally, patients with TOF had significantly higher arterial wave reflection than the controls (reflection coefficient: 0.21 (0.12) vs 0.16 (0.06)). These abnormalities in patients with TOF increased the pulsatile load on the left ventricle and significantly contributed to decreased cardiac output, even when right ventricular function was taken into account by multivariate regression analysis. The increase in aortic wall stiffness was closely associated with the increase in aortic root diameter. CONCLUSION: These results indicating abnormal arterial haemodynamics after TOF repair highlight the importance of regular monitoring of the systemic arterial bed and potentially relevant cardiovascular events in long-term follow-up of TOF.

Assessment of cardiovascular dynamics by pressure-area relations in pediatric patients with congenital heart disease.

OBJECTIVES: It is particularly useful to separately quantify the ventricular contractility and loading conditions for a better understanding of the cardiovascular dynamics in congenital heart disease, where abnormalities in chamber and loading properties may coexist. Furthermore, ventricular contractility and loading conditions may alter independently or simultaneously with disease progression and therapeutic intervention. The objectives of the present study were (1) to test whether ventricular pressure-area analysis can provide such quantitation among patients with various forms of congenital heart disease, (2) to reveal basal cardiovascular interaction in congenital heart disease by means of pressure-area analysis, and (3) to test the feasibility of this method in a simplified and less invasive form to further enhance its clinical value. METHODS: We constructed pressure-area loops during caval occlusion by using transthoracic echocardiographic automated border detection combined with ventricular pressure recordings in 59 pediatric patients with congenital heart disease and in 7 normal control subjects. RESULTS: Area measurements obtained by automated border detection were highly reproducible, and area changes reflected volume changes. The pressure-area data provided load-independent measures of contractility, which were consistently increased by use of dobutamine (P <.05). End-systolic and arterial elastance individually quantified simultaneous changes in ventricular contractility and loading with milrinone infusion and predicted net cardiac performance. The pressure-area analysis better characterized the ventricular contractile states under a variety of loading conditions in congenital heart disease, whereas predominant load dependence of conventional indices confounded them. Furthermore, pressure-area relations were reasonably estimated from a single beat and from aortic pressure data during abdominal compression. CONCLUSIONS: Pressure-area analysis should provide a useful modality with which to assess cardiovascular dynamics in pediatric patients with congenital heart disease in more detail and should thus help improve the management of patients with this disease.

Inferior vena cava occlusion catheter for pediatric patients with heart disease: for more detailed cardiovascular assessments.

Traditional evaluation of cardiac function is too often limited by reliance on measurements with complex interdependence between cardiac properties and loading factors. Analysis by ventricular pressure-volume (P-V), -area (P-A), or -dimension (P-D) relations during inferior vena caval (IVC) occlusion independently quantifies ventricular properties and loading conditions, providing detailed information about cardiovascular dynamics. However, there has been no appropriate size of balloon catheter that can effectively occlude IVC of pediatric patients, hindering the application of P-V (P-A, or P-D) analysis to children with heart disease despite its potential benefit. To address this problem, we have developed a new balloon catheter for IVC occlusion in children. The catheter effectively occluded IVC in 92 pediatric patients with varying forms of heart disease who underwent cardiac catheterization, yielding end-systolic pressure-area relations. Thus a newly developed balloon catheter would contribute to establishing more accurate and detailed cardiovascular assessments in children with heart disease. Cathet Cardiovasc Intervent 2001;53:392-396.

[Single-dose and high-volume Bretschneider cardioplegic solution for congenital heart surgery].

Bretschneider cardioplegic solution is used widely in Europe. The aim of this study is to investigate the efficacy of Bretschneider cardioplegic solution for open heart surgery of congenital heart disease in comparison with blood cardioplegia. From June 1995 to July 1997, we treated 32 congenital heart disease patients using Bretschneider cardioplegic solution and 20 patients using blood cardioplegia. Hospital mortality, water balance during operation, percentage of arrhythmia, and intubation time were not significant in both group. Also CPK and CPK-MB were not significant in both group. Bretschneider cardioplegic solution had preserved the heart as same as blood cardioplegia. This is a very convenient method so that we can use only one time infusion.

Change of renal function during vancomycin therapy in extremely low birthweight infants.

Twenty extremely low birthweight infants were treated with vancomycin (VCM). Their gestational age was 26.3 +/- 1.4 weeks (range 24.0-28.7 weeks) and their birthweight was 829 +/- 133 g (range 562-900 g). At the time of initial administration of VCM, postnatal age was 29.5 +/- 15.8 days (range 5-54 days). Vancomycin was administered in a dose between 9.3 and 11.0 mg/kg every 12 h for a period of 6.3 +/- 2.4 days (range 4-13 days). Serum and urinary specimens were obtained before and after (within 24 h following the last dose) VCM therapy. Serum creatinine and sodium, and urinary N-acetyl-beta-D-glucosaminidase (NAG) activity, creatinine, sodium, and beta-2-microglobulin (BMG) concentrations were measured. Fractional excretion of sodium (FENa) and NAG index (NAG:creatinine ratio) were calculated. There were no significant differences between the before and after VCM treatment in serum creatinine, urinary BMG concentration, FENa and NAG index. No infant showed any symptoms of renal insufficiency. However, the NAG index and FENa increased after treatment in 1 of 20 infants. Vancomycin is effective and safe in the treatment of serious infections in extremely low birthweight infants.

Theophylline-induced seizures in a 6-month-old girl. Serum and cerebrospinal fluid levels.

The case is presented of a 6-month-old girl with theophylline-induced focal seizures associated with tachycardia, tremor and irritability. The serum level of theophylline was 20.0 micrograms/ml 30 min after the onset of seizures, and declined to half this level at 19 h. The ratio of the concentration in cerebrospinal fluid (CSF; 8.9 micrograms/ml) to serum (16.4 micrograms/ml) was 0.54 at 4.5 h after the onset. Despite the cessation of seizures, the EEG showed periodic high voltage delta waves over the right hemisphere and left-sided flatness. Since theophylline diffuses easily through the blood-brain barrier in infancy, serum levels should be maintained below 15 micrograms/ml unless severe bronchial asthma occurs.

A case of gastric duplication cyst with aberrant pancreas.

The radiographic and computed tomographic findings of a gastric duplication cyst contiguous to the stomach first diagnose in a 13-year-old-woman are presented. She revealed pyloric stenosis and chronic relapsing pancreatitis. In the smooth muscle wall and the connective tissue of the cyst lay aberrant pancreatic tissue and large neural bands.