Propranolol versus captopril in the treatment of infantile hemangioma (IH): A randomized controlled trial.

BACKGROUND: Renin-angiotensin system components have been demonstrated in the biology of infantile hemangioma (IH). Captopril, an angiotensin-converting enzyme inhibitor, is proposed as a therapeutic alternative to oral propranolol. OBJECTIVES: We sought to compare the benefit of propranolol and captopril in the treatment of IH, and to assess angiotensin-converting enzyme gene polymorphism in patients with IH and in control subjects. METHODS: Thirty patients with IH and 35 healthy control subjects were enrolled in this study. Patients were randomly assigned to treatment with either propranolol or captopril. Assessment was done clinically and by measurement of serum vascular endothelial growth factor and angiotensin II in patients and control subjects. Angiotensin-converting enzyme gene polymorphism was also studied. RESULTS: Clinical improvement was significantly better and faster in the patients treated with propranolol. Both groups showed reduced vascular endothelial growth factor and angiotensin II levels posttreatment, with a significantly higher percentage reduction in the propranolol-treated group. Cardiac side effects were reported only in the captopril-treated group. Baseline vascular endothelial growth factor level was significantly higher, and baseline angiotensin II level was significantly lower, in patients than control subjects. LIMITATIONS: We studied a relatively small number of patients and control subjects. CONCLUSION: Propranolol shows greater benefit than captopril in the treatment of IH.

Oral propranolol: an effective, safe treatment for infantile hemangiomas.

Infantile hemangiomas (IH) are the most common childhood tumors. In 2008, Labreze reported the serendipitous effect of oral propranolol on hemangioma and since then it has overshadowed the use of other therapeutic modalities in the treatment of IH. The aim of this prospective, clinical study was to assess the efficacy and safety profile of oral propranolol at a fixed dose of 2 mgkg(-1) in the treatment of 30 patients with problematic IH. Propranolol treatment continued for a duration of 2-14 months where 60% of the patients (n=18) showed a final excellent response with complete resolution of the lesion (P<0.001). 20% (n=6) showed a good response with more than 50% reduction in the size of the IH. 16.6% showed a fair response (n=5) with less than 50% reduction in the size of the IH. Only one patient (3.3%) was resistant to treatment. Five patients (17.24%) showed evidence of rebound growth after cessation of therapy and responded well to re-treatment.We did not face any side effects related to the oral propranolol. In conclusion, propranolol therapy at a fixed dose of 2 mgkg(-1), given in three equally divided doses, is a very safe and effective regimen in the treatment of IH.

Arrhythmia in the neonatal intensive care unit.

A random sample of 457 neonates was prospectively studied in order to identify the incidence, common types, and risk factors for arrhythmias in the neonatal intensive care unit (NICU). A 12-lead EKG was studied in all neonates (n = 457). A total of 139 Holter studies was done in every fourth baby with a normal EKG (n = 100) and in all babies with an abnormal EKG (n = 39). Of the 100 infants who were thought to be arrhythmia-free by EKG, nine infants demonstrated an arrhythmia on Holter studies. When we correlated screening results with maternal, obstetrical, and neonatal risk factors; arrhythmias were significantly associated with male gender, more mature gestational age, lower glucose levels, maternal smoking, high umbilical artery lines, and the use of the nebulized beta-2 adrenergic treatment, whereas umbilical venous lines and dopamine infusion did not relate to arrhythmia. We conclude that arrhythmias are more common in the NICU than in the general neonatal population. Compared to Holter monitoring, the sensitivity of the EKG was only 89%.

Diagnostic dilemma of cardiac syncope in pediatric patients.

AIMS: Syncope is defined as temporary loss of consciousness and postural tone resulting from an abrupt transient decrease in cerebral blood flow. The present work aimed at determining how diagnostic tests are used in the evaluation of pediatric syncope at a tertiary pediatric referral center and to report on the utility and the yield of these tests. SETTINGS AND DESIGN: Retrospective study conducted at a tertiary referral arrhythmolology service METHODS AND MATERIAL: The clinical charts of 234 pediatric patients presenting with a primary complaint of syncope with an average age of 7.48 +/- 3.82(3.5-16) years were reviewed by the investigators. STATISTICAL ANALYSIS USED: Statistical Package of social science (SPSS) version 9,0 was used for analysis of data. RESULTS: The commonest trigger for syncope in the study population was early following exercise (n=65) and the commonest prodrome was palpitation, noted in 25 patients. A murmur was present in 19 of our patients (8.3%) while 10.7% (n=25) had abnormal ECGs. Of the 106 echocardiograms done, 14 (13.2%) were abnormal. Only two of them were missed by ECG. All patients were offered ambulatory 24 hour ECG. One patient with sick sinus syndrome was diagnosed only with Holter. CONCLUSIONS: Clues to the presence of cardiac syncope may include acute onset of syncope, frequent episodes, low difference between blood pressure readings in supine and erect positions (after standing for 2 minutes) and most importantly an abnormal 12 lead ECG. Transthoracic echo and Holter monitoring have low yield in pediatric syncope.

The value of Holter monitoring in the assessment of Pediatric patients.

AIMS: Holter monitoring (HM) has been established as one of the most effective noninvasive clinical tools in the diagnosis, assessment and risk stratification of cardiac patients. However, studies in the pediatric age group are limited. The present work aims at determining the value of HM in the diagnosis and management of children. SETTINGS AND DESIGN: Retrospective study conducted at a tertiary referral arrhythmolology service. METHODS AND MATERIAL: Holter records of 1319 pediatric patients (54.1% males and 45.9% females) were reviewed. Their average age was 6.7+/- 4.1 years (5 days-16 years). Indications for which Holter monitoring was done were analysed as well as all the abnormalities diagnosed and factors that may increase Holter yield. STATISTICAL ANALYSIS USED: Statistical Package of social science (SPSS) version 9,0 was used for analysis of data. RESULTS: The most common indications were palpitations (19.8%), syncope (17.8%), cardiomyopathy (12.6%), chest pain (10%), evaluation of antiarrhythmic therapy (6.8%), postoperative assessment (2.6%) and complete AV Block (2.4%). A sum of 141 Holter recordings were found abnormal with a total diagnostic yield of 10.7%. The highest contribution to diagnosis was in postoperative assessment (32.4%) and in cardiomyopathy (19.9%) where the most common abnormalities were frequent supraventricular / ventricular premature beats, supraventricular tachycardia, ventricular tachycardia and AV block. Diagnostic yield was low in patients with palpitations (5.7%) and syncope (0.4%). An abnormal ECG was significantly associated with a higher diagnostic yield (p=0.0001). None of the children with chest pain had abnormal Holter recordings. CONCLUSIONS: HM has an extremely valuable role in the assessment of high risk patients (postoperative and cardiomyopathy). However in children with palpitations, syncope and chest pain HM has a low yield. In this group of patients an abnormal ECG is more likely to be associated with abnormal Holter recordings.

Transcatheter closure of secundum ASD using Occlutech Figulla-N device in symptomatic children younger than 2 years of age.

INTRODUCTION: Atrial septal defect (ASD) transcatheter occlusion techniques have become alternatives to surgical procedures. We evaluated the efficiency and safety of the Occlutech Figulla-N device in percutaneous closure of secundum ASDs in symptomatic children younger than 2 years of age. METHODS: The study included 17 patients (9 girls, 8 boys; mean age, 10.3 ± 2.1 months). Mean weight was 7.4 ± 1.3 kg, with secundum ASDs measuring more than 8 mm with a hemodynamically significant shunt, resulting in failure to thrive, right ventricular dilatation, and pulmonary hypertension. Two girls had fenestrated ASD secundum. Defect size and total interatrial septal length were estimated by transthoracic (TTE) and transesophageal (TEE) echocardiography in 3 views. Procedures were performed under fluoroscopic and TEE guidance. Patients were followed-up at 1, 3, 6, and 12 months with TTE. RESULTS: The mean defect size was 15.4 ± 2.7 mm on TTE and 17.1 ± 1.9 mm on TEE. The mean device size was 17.8 ± 3.6 mm (range, 10 to 24 mm). The mean pulmonary artery pressure was 54 ± 18 mm Hg. The device was placed successfully in all patients including fenestrated ASDs that were closed with a single device placement. No residual flow was seen after device placement in patients. Complications were seen in 2/17 patients (11.8%) in the form of sinus tachycardia in 1 patient and femoral vein hematoma in 1 patient. At 6 and 12 months, all the patients were asymptomatic. No cardiac perforation, device erosion, embolization, thrombus formation, or malposition of the device was observed. Three patients developed mild insignificant mitral regurgitation. CONCLUSIONS: ASD closure in severely symptomatic children younger than 2 years of age using the Occlutech Figulla-N occluder is safe and efficient. Meticulous care to patient selection, adequate defect sizing, and device size selection are keys to lower incidence of complications.

Propranolol and infantile hemangiomas: different routes of administration, a randomized clinical trial.

UNLABELLED: Oral propranolol has become the treatment of choice of infantile hemangiomas (IH)s. However, the safety of systemic propranolol is questioned. Topical therapy with 1% propranolol has been reported to be safe and effective. Intralesional (IL) administration may possibly allow safe delivery of higher drug dosages. AIM: To assess the efficacy and safety of two locally administered routes of propranolol (topical and IL), in comparison with its systemic oral use in the treatment of IHs. PATIENTS AND METHODS: 45 patients with IHs were randomly divided into 3 groups, A, B and C (n = 15 in each), receiving oral propranolol, 2 mg/kg/day, topical propranolol 1% ointment twice daily, IL propranolol, 1 mg of propranolol hydrochloride in 1 ml of injection once weekly, respectively. Follow up was done for 6 months after treatment was stopped. RESULTS: Excellent response was achieved in 9 patients in group A (60%), 3 in group B (20%) and 2 in group C (13.3%), (P value : 0.04). As regards safety, all 3 modalities proved safe with no major side effects apart from 1 patient in group A and 3 in group C who dropped out due to pain or inconvenience of therapy. CONCLUSIONS: Further work is needed to establish clear guidelines and reach best formulations. Nevertheless, in properly selected patients with IHs, we recommend the usage of oral propranolol. Topically administered propranolol could be considered in patients at risk of potential side effects from oral administration. As IL application did not offer any more benefits, it could not be recommended.

Percutaneous closure of medium and large PDAs using amplatzer duct occluder (ADO) I and II in infants: safety and efficacy.

BACKGROUND: The use of the Amplatzer duct occluder (ADO; AGA Medical Corporation) is well established and reported in children and adults, but there are only occasional reports on use in symptomatic infants. METHODS AND RESULTS: Between March 2009 and January 2011, a group of 47 infants less than 2 years of age with symptomatic patent ductus arteriosus (PDA) was treated using ADO I and II devices. Patients were divided into infants less than 1 year old (group A; n = 28/47; 59.6%) and children between 1 and 2 years old (group B; n = 19/47; 40.4%). Physical examinations and echocardiograms were performed before the procedure and at follow-up (3, 6, and 12 months). Mean age was 5.3 ± 2.3 months for group A and 12.6 ± 1.7 months for group B. Mean weight at closure was 4.8 ± 1.9 kg for group A and 7.3 ± 2.1 kg for group B. ADO I was deployed in 19/28 of group A (67.9%) and 16/19 of group B (84.2%). ADO II was used in 9/28 of group A (32.1%) and 3/19 of group B (15.8%). No residual shunt at the end of the procedure was detected by angiography in any of the cases closed with ADO I and only 3/12 (25%) closed with ADO II showed a minimal residual flow. No mortality or major complications occurred. Six months after closure, weight gain, control of respiratory infections, and regression of left ventricular dilatation with improved systolic function were observed. CONCLUSIONS: Percutaneous closure of moderate to large PDAs using ADO I and II devices in infants and children younger than 2 years of age is safe and effective.