Role of transvenous implantable cardioverter-defibrillators in preventing sudden cardiac death in children, adolescents, and young adults.

OBJECTIVE: To evaluate the indications, underlying cardiac disorders, efficacy, and complications involved with transvenous implantable cardioverter-defibrillators (ICDs) in pediatric patients at the Mayo Clinic. PATIENTS AND METHODS: The records of all patients aged 21 years or younger who underwent transvenous ICD placement at the Mayo Clinic, Rochester, Minn, were reviewed retrospectively. RESULTS: Between March 1992 and September 2000, 16 patients (7 females; mean age, 15.4 years; range, 10-21 years) underwent transvenous ICD placement. The ICD was implanted for primary prevention of sudden cardiac death in 7 and for secondary prevention in 9. The underlying cardiac disorders included hypertrophic cardiomyopathy in 6 patients and congenital long QT syndrome in 6 patients. The mean +/- SD follow-up was 36+/-29 months (range, 5-108 months). There was no mortality. Seven patients (44%) received appropriate ICD therapy, including 6 of 9 who had ICDs placed for secondary prevention. Median time free from appropriate ICD discharge was 3 years (range, 0.2-9 years). Three patients (19%) experienced inappropriate ICD discharge. Two patients needed device replacement because of technical problems (lead fracture and device malfunction). Two patients developed pocket infection that required removal and reimplantation of the ICD. CONCLUSION: In adolescents and young adults, transvenous ICDs may prevent sudden death but are not free of complications. Forty-four percent of this cohort received potentially life-saving ICD therapy, including two thirds who received an ICD for secondary prevention.

Sex-specific changes in platelet aggregation and secretion with sexual maturity in pigs.

Cardiovascular disease may begin early in adolescence. Platelets release factors contributing to vascular disease. Experiments were designed to test the hypothesis that hormonal transitions associated with sexual maturity differentially affect platelet aggregation and secretion in males and females. Platelets were collected from juvenile (2-3 mo) and sexually mature (adult; 5-6 mo) male and female pigs (n=8/group). Maturation was evidenced by increased weight of reproductive tissue and changes in circulating levels of gonadal hormones. Aggregation to ADP (10 microM) and collagen (6 microg/ml) and ATP secretion to 50 nM thrombin were determined by turbidimetric analysis and bioluminescence, respectively. Total platelet counts, platelet turnover, and mean platelet volume did not change with maturity. Platelet aggregation and ATP secretion decreased in females but increased in males with maturity, whereas total ATP content remained unchanged in platelets from females but increased in platelets from males. Platelet fibrinogen receptor, P-selectin expression, and receptors for sex steroids did not change with sexual maturation. Plasma C-reactive protein and brain-type natriuretic peptide also did not change. Results indicate that changes in platelet aggregation and secretion change with sexual maturity differently in females and males. These observations provide evidence on which clinical studies could be designed to examine platelet characteristics in human children and young adults.

Effect of puberty on coronary arteries from female pigs.

Vascular function changes following loss of ovarian hormones in women at menopause and in experimental animals following surgical ovariectomy. Little is known about changes in vascular function during hormonal transition from sexual immaturity (juvenile) to sexual maturity. Therefore, experiments were designed to determine effects of natural puberty on vascular function in female pigs. Tissue was studied from eight juvenile (2-3 mo) and eight adult (5-6 mo) female pigs. Plasma nitric oxide (NO) was measured, and mRNA for endothelium-derived NO synthase (eNOS) and eNOS protein were determined in aortic endothelial cells. Rings of coronary arteries were suspended for measurement of isometric force in organ chambers. Serum 17beta-estradiol levels were comparable in the two groups, whereas the arithmetic mean of progesterone levels was about two-thirds lower in adults compared with juvenile pigs. Plasma NO was significantly higher in juveniles compared with adults, but mRNA and protein for eNOS were comparable. In coronary arteries, an alpha2-adrenergic agonist caused greater endothelium-dependent relaxations in rings from juvenile compared with adult pigs. Relaxations to bradykinin were similar in arteries from both groups, but inhibition of NO reduced relaxations only in arteries from juvenile pigs. Relaxations from NO were greater in arteries from adult compared with juvenile female pigs. In conclusion, coronary arterial endothelial and smooth muscle responses are selectively modulated at puberty in female pigs. At maturity, plasma NO is reduced and sensitivity of the smooth muscle to exogenous NO is increased. Posttranscriptional regulation of eNOS protein may explain differences in NO bioavailability in juvenile pigs.

Left atrial isomerism: clinicopathologic findings in a 14-year-old boy.

Visceral heterotaxy syndromes have been associated with complex congenital heart disease and several attempts have been made to classify these lesions. One area of controversy that remains is the existence of atrial isomerism. In this case report we provide definite anatomic evidence of the existence of left atrial isomerism, wherein both the atria have smooth walls, finger-like appendages, and absence of the pectinate muscles and sinus node.

Fenestrated Amplatzer device for percutaneous creation of interatrial communication in patients after Fontan operation.

A customized Amplatzer septal device with a 5 mm fenestration was used to create an interatrial communication in two patients with previous Fontan operation and clinical indication for fenestration. At follow-up, device fenestration was occluded in both patients. In both patients, the device fenestration was reopened and patency maintained by placement of two stents within the communicating channel.

Endothelium-dependent responses in coronary arteries are changed with puberty in male pigs.

In humans, cardiovascular disease begins in young adulthood and is more prevalent in males than females. However, little is known about vascular function during transition to adulthood in males. The aim of this study was to define changes in production of endothelium-derived nitric oxide (NO) and coronary arterial responses during puberty. Plasma was collected from juvenile (2-3 mo of age) and adult (5-6 mo of age) male pigs (n = 8/group) for measurement of NO, and aortic endothelial cells were collected for measurement of mRNA and protein for endothelial NO synthase (eNOS). Although plasma NO was higher in juvenile (67.0 +/- 25.6 microM) than in adult (15.0 +/- 7.1 microM) male pigs, eNOS protein was similar in both groups. However, levels of mRNA for eNOS were lower in aortic endothelial cells from juvenile pigs. In rings of coronary arteries suspended in organ chambers for measurement of isometric force and contracted with PGF2alpha, relaxations to an alpha2-adrenergic agonist were significantly inhibited by indomethacin only in juvenile pigs [EC50 (-log M), 6.7 +/- 0.3 with indomethacin and 7.7 +/- 0.3 under control conditions]. NG-monomethyl-l-arginine (l-NMMA) inhibited relaxations in both groups. On the contrary, in the presence of indomethacin, relaxations to bradykinin were inhibited by l-NMMA only in arteries from adult pigs [EC50 (-log M), 8.9 +/- 0.3 with indomethacin and 8.6 +/- 0.3 with addition of l-NMMA]. These results suggest that hormonal changes associated with sexual maturity may affect posttranscriptional and/or translational regulation of eNOS protein and result in lower plasma NO in adult male pigs. In addition, endothelium-derived inhibitory cyclooxygenase products seem to predominate in juveniles.