Antithrombotic therapy in children and adolescents.

This report documents our experience with long term antithrombotic therapy (acenocoumarol plus aspirin) in 31 children and adolescents, from 5 months to 16 years of age. The valves replaced were mitral in 20 patients, aortic in 4, mitral-aortic in 4 and tricuspid in 3; the overall follow-up time was of 1336 months. Anticoagulant requirement in each children was not in correlation with age, but a significant increase (p less than 0.01) was found in association with sexual development. Our total incidence of embolic episodes was 1.49/1000 patient-months. The embolic incidence on adequate anticoagulated patients was 0.74/1000 patient-months and 93.7% of all patients were free of thrombo-embolic accidents up to 96 months of follow-up. Minor haemorrhage in relation to an excess of anticoagulant was 1.49/1000 patient-months. There has been only one major bleeding episode associated with severe sepsis, with an incidence of 0.74/1000 patient-months. No major difficulties were found in the management of anticoagulant treatment and its association with antiplatelet drugs in children.

A comparative long-term follow-up of the results of anterior and posterior approaches in bypassing the rudimentary right ventricle in patients with tricuspid atresia.

We have studied 44 patients with classical tricuspid atresia who underwent radical surgery between 1971 and 1985. Bypassing of the incomplete and rudimentary right ventricle was performed, in anterior fashion, in 17 patients operated on from 1971 to 1980. Subsequently, from 1980 to 1985, we used a technique of posterior retroaortic atriopulmonary anastomosis. This was undertaken in 27 patients. We have now compared the results in the two groups. Hospital and late mortality was 23.5 and 17.6% in those undergoing an anterior anastomosis, while it was 7.4 and 3.7% in those having a retroaortic connexion. When we compared the results in survivors, according to a previously designed clinical assessment score, we found that 41.1% of those undergoing the anterior approach were in excellent clinical status in comparison to 85.1% of those having a posterior anastomosis. The actuarial survival curve at 6 years showed 88.8% survival (70% confidence limit 44-77) for the posterior approach and 64.7% for the anterior. On the basis of our findings we felt able to remove from consideration as risk factors three of the features initially identified by Choussat and his colleagues. We conclude that better immediate and late results are obtained with the posterior retroaortic approach. We also found that those patients with excellent long-term outcome had postoperative right atrial pressures less than 14 mm Hg. Late arrhythmias were associated with increased right atrial pressures and were a relevant risk factor in both groups.

[Problems in the management of patients with inoperable cardiac anomalies]. / Problemas en el manejo de enfermos con anomalíacas inoperables.

A general review of the main problems found in the management of inoperable heart anomalies is made by the author. He determines the reasons why a heart disease cannot be corrected by surgery, the complications found in such cases, the cautiousness that must be taken and the psychological aspect of these problems in relationship with the family and the patient.

Long-term systemic hypertension in children after successful repair of coarctation of the aorta.

The mechanisms responsible for long-term hypertension in children after successful repair of coarctation of the aorta have not yet been determined. We measured plasma renin activity and aldosterone, adrenalin, and noradrenalin concentrations both under basal conditions and in response to standing and treadmill exercise in 24 normal normotensive children, 16 normotensive postcoarctectomy children, eight hypertensive postcoarctectomy children, and seven children with essential hypertension. Exercise-induced changes in plasma renin activity, aldosterone, adrenalin, and noradrenalin were comparable in the four groups in spite of a significantly greater increase in systolic blood pressure in the children with hypertension. In response to standing, the plasma concentration of noradrenalin increased significantly in normotensive but not in hypertensive children. Hyperresponse of blood pressure to exercise in hypertensive postcoarctectomy children and children with essential hypertension is not related to abnormalities in the sympathetic nervous system or the angiotensin-aldosterone axis. Hypertension could be related to primary baroreceptor alterations, to structural changes in the arterial wall, or both. Twenty percent of normotensive postcoarctectomy children had a blood pressure hyperresponse to exercise and an abnormal noradrenalin response to standing similar to that seen in the hypertensive children. Follow-up of children after coarctectomy may elucidate whether these two abnormalities are indicators of an increased risk of developing long-term recurrent hypertension.

Transient cardiac constriction following purulent pericarditis.

Transient cardiac constriction is an unusual complication of purulent pericarditis. It should be suspected in the presence of clinical and haemodynamic deterioration when signs of activity have abated. Features of cardiac constriction were observed in a 4-year-old boy 2 weeks after surgical drainage. The patient was managed conservatively without surgery and the outcome was good. Follow up 2 years later showed a healthy boy with a normal cardiological examination.

Early (stage A) prostatic cancer. VI. A critical look at the follow-up.

The 4 year follow-up of an original series of 100 patients treated by subtotal prostatectomy and analysed on histopathological grounds is presented. 87 out of 100 were traced and were in the following groups: 37/45 A1, 27/29 A2, 10/12 A3, 13/14 benign prostatic hyperplasia. No therapy was performed. All three patients who died of prostatic carcinoma fitted into substage A3, all three patients living with metastases fitted into A1. The progression observed is significant when related to the brief interval of time, the size of the prostatic microcarcinoma and the histological grade (well differentiated tubular carcinomas in 5 out of 6 cases). Prostatectomy with capsulectomy is strongly recommended in order to prevent progression.

Methotrexate, vinblastine, epidoxorubicin and cisplatin (M-VEC) in patients with locally advanced transitional bladder cancer.

M-VEC (methotrexate, vinblastine, epidoxorubicin and cisplatin), a new combined drug regimen in which epidoxorubicin has been substituted to adriamycin to reduce the toxicity of the original M-VAC chemotherapy, has been tested in 23 patients with locally advanced transitional cell bladder cancer (TCBC) (stage T2-T4 No Mo). After two to four courses, an objective response was observed in 19 patients, with 13 clinical complete responses. Seven patients underwent cystectomy after chemotherapy: one patient had no residual tumor on bladder specimens, five patients had a surgical eradication of the disease, while one patient had only a partial resection. Eight relapses of bladder carcinoma were observed, three among the surgically treated patients and five among patients who did not undergo cystectomy, with a median time-to-relapse of 9.7 months. Progression-free survival at 24 months was 52.3%. M-VEC regimen appears to be effective in locally advanced TCBC, with acceptable toxicity.