Cardiac complications during pregnancy are better predicted with the modified WHO risk score.

BACKGROUND/OBJECTIVE: Several risk scores (RSs) have been used to stratify risk of cardiac complications (CCs) in pregnant patients with heart disease. We aimed to compare and contrast the accuracy of several RSs for predicting CC in this population. METHODS: Prospective inclusion of all consecutive pregnant patients with heart disease, and follow-up until 6 months postpartum. CCs were defined as primary if admission was required due to heart failure, arrhythmia or thromboembolic events, and secondary if the decline in NYHA class compared with baseline was >2 or urgent invasive cardiac procedures were needed. The discriminatory power of each RS was assessed by the area-under-the receiver-operating characteristic (ROC) curve (AUC). RESULTS: 179 patients, mean age: 32 years, accounted for 13.4% of CC (primary 11.7%, secondary 1.7%); the main diagnosis was congenital heart disease (CHD) in 68% followed by valvulopathies in 16%, arrhythmia in 7% and myocardiopathies in 5%. 22% (n=40) were classified as mWHO=1, 59% (n=105) mWHO=2 including subgroup 2-3, 14% (n=26) mWHO=3 and 4%(n=7) mWHO=4; 1 patient was unclassifiable. mWHO showed a better AUC (0.763) than CARPREG (0.67). For the CHD population, ZAHARA RS showed an AUC of 0.74, and Khairy an AUC of 0.632. CONCLUSIONS: mWHO was better at predicting CC than CARPREG; mWHO was also better at predicting CC than the specific CHD RS in the CHD subgroup. PRACTICE: There are an increasing number of pregnant women with HD. IMPLICATIONS: Improved prediction of CC risk during pregnancy can provide better preconception assessment in women with HD.

[Percutaneous closure of a mid-muscular residual ventricular septal defect using the Amplatzer(TM) device]. / Cierre percutáneo de una comunicación interventricular muscular residual mediante el dispositivo tipo Amplatzer.

We present the case of a 6-year old boy with a mid-muscular residual ventricular septal defect (VSD) of difficult surgical access, who underwent transcatheter closure using the Amplatzer(TM) VSD occluder. Transcatheter closure was guided by transthoracic echocardiography and successful closure was achieved with a 12 mm diameter VSD occluder, with no complications. Chest radiography showed a considerable decrease in cardiomegaly and normalization of pulmonary vascular markings before 24 hours, and echocardiography showed correct positioning of the Amplatzer(TM) VSD device without residual shunt through the device and minimal residual shunt in an apical VSD. After a 3-month follow-up, the patient was asymptomatic and echocardiography showed that the device was correctly positioned with minimal residual apical shunt.

Cierre percutáneo de una comunicación interventricular muscular residual mediante el dispositivo tipo Amplatzer / Percutaneous closure of a mid-muscular residual ventricular septal defect using the amplatzer device

Se presenta el caso de un niño de 6 años de edad, afectado de una comunicación interventricular (CIV) muscular residual medioventricular de difícil acceso quirúrgico, en la que se procedió al cierre mediante cateterismo con el dispositivo Amplatzer Muscular VSD Occluder. El procedimiento se realizó guiado por ecocardiografía transtorácica consiguiendo la implantación del dispositivo de 12 mm de tamaño sin incidencias ni complicaciones. A las 24 h el paciente fue dado de alta previa realización de una radiografía de tórax que muestra una disminución importante tanto de la cardiomegalia como de la circulación pulmonar y una ecocardiografía que evidencia el dispositivo correctamente situado en el tabique interventricular sin flujo a su través, y con una CIV residual mínima. Tras un seguimiento de 3 meses el paciente esta asintomático y la ecocardiografía muestra el dispositivo correctamente situado con mínima CIV residual apical (AU)

[Transposition of the great arteries and pulmonary hypertension: inhaled nitric oxide as a therapy and early surgical correction]. / Transposición de grandes arterias e hipertensión pulmonar: tratamiento con óxido nítrico inhalado y corrección anatómica precoz.

OBJECTIVE: The objective of this study is to present our preliminary experience with pulmonary hypertension inhaled nitric oxide therapy with two newborns presenting with transposition of the great arteries, as well as the usefulness of the Doppler in pulmonary hypertension diagnosis. PATIENTS AND METHODS: Revision of the variations of the hypoxic parameters according to the therapy and revision of the diagnostic procedures in both cases was carried out. RESULTS: Nitric oxide therapy was followed by an evident improvement of the hypoxia and the patient's hemodynamic stabilization, which allowed surgical correction in optimal conditions. The ductal flow pattern allowed recognition of the presence of pulmonary hypertension. CONCLUSIONS: Inhaled nitric oxide must be taken into account as a very useful option in the treatment of this kind of patient and the Doppler examination allows the evaluation of the presence of pulmonary hypertensions.

[Influence of coronary anatomy on the anatomic repair of transposition of great arteries]. / Influencia de la anatomía coronaria en la corrección anatómica de la transposición de grandes arterias.

INTRODUCTION: The anatomic diversity of the coronary artery and the alignment of the aortic and pulmonary valves have special importance on the surgical anatomic correction of the transposition of the great arteries and double outlet of the right ventricle, because of their repercussions on surgical technique and the effect on the operative results. OBJECTIVE: To determine the coronary artery pattern; the aortic and pulmonary valve alignment, and their effects on the surgical results in 57 patients submitted to anatomic correction in our hospital. METHOD: We used the Yacoub and Radley-Smith patterns in order to classify the different coronary distributions. The relation between the coronary pattern and degree of alignment with surgical difficulty and the mortality rate was examined. The coronary pattern established by echocardiography was compared with the surgical findings in the last 16 patients. RESULTS: 31 patients belonged to group A, 3 to B, 2 to C, 19 to D and 2 to E. There was no difference in the extracorporeal circulation time among the groups, although the difficulty in the coronary transfer was not the same among them. Type E mortality rate was 50%, type B 33%, and type D 5.2%. There were no deaths in the other groups. Malalignment was found in the three patients who died. The coronary pattern found by echocardiography was confirmed in 13 patients whose images were quite clear. CONCLUSIONS: Coronary pattern and the malignment affect both surgical difficulty and mortality rate of patients undergoing anatomic correction. Bidimensional-echocardiography is useful to demonstrate the different coronary patterns in most cases.

[Ebstein's anomaly of the tricuspid valve. Apropos 35 cases]. / Anomalía de Ebstein de la válvula tricúspide. A propósito de 35 casos.

Ebstein's anomaly of the tricuspid valve is a relatively uncommon congenital heart defect which consists of an apical displacement of the valvar annulus with a deformity of the septal and posterior leaflets. We report 35 cases studied from 1969 to 1993 (45% males and 55% females). One patient presented a polymalformation syndrome and another had a case of Ebstein's anomaly amongst his siblings. We performed an echocardiography in 31 patients and a catheterization in 15. The mean follow-up was 7.6 years (range: 1 day to 16.1 years). The diagnosis was established during the neonatal period in 66.7%. We found other associated cardiac anomalies in 57.1%, with radiologic cardiomegaly in 80.7%. Upon analysis of the EKGs, the P wave was higher than 0.3 mV in 48.4% and 16.1% showed Wolff-Parkinson-White syndrome. Paroxysmal supraventricular tachycardia developed in 12.9%. Long term cardiotonic treatment was needed in 27.3%. In 24.2% cardiac surgery was performed, including one heart transplantation. The mortality rate was 27.3%. The severity of Ebstein's anomaly is extremely variable, not only in its anatomy, but also in the clinical presentation. The severe neonatal form, the associated cardiac defects and heart failure worsen the prognosis.

[Usefulness of nuclear magnetic resonance in the diagnosis of aortic coarctation and recoarctation]. / Utilidad de la resonancia nuclear magnética para el diagnóstico de la coartación y recoartación aórtica.

OBJECTIVE: To assess nuclear magnetic resonance (NMR) usefulness in aortic coarctation and recoarctation diagnosis. MATERIAL: 46 NMR performed on 43 patients: aortic coarctation was suspected in 30 patients and recoarctation in 13 by means of clinical, echocardiographic and Doppler examination. METHOD: Comparison of the NMR observations with the previous diagnosis and the surgical and therapeutic catheterism findings. RESULTS: 41 patients were diagnosed of aortic coarctation or recoarctation by NMR, although a second examination was needed in 3 cases. This diagnosis was confirmed in the 26 treated children (surgical treatment or by angioplasty). CONCLUSIONS: NMR offers excellent aortic images; positive diagnoses have a high safety level, but patients with negative diagnoses must be clinically followed; children suffering from native coarctation can be operated without previous angiographic examination.

[Aortic coarctation in the neonatal period. Study of 137 cases]. / Coartación aórtica en el período neonatal. Estudio de 137 casos.

The clinical records of 137 newborns, diagnosed by cardiac catheterization of aortic coarctation, have been reviewed. According to the presence of associations, three different groups have been established. Group A: isolated coarctation or coarctation associated with patient ductus arteriosus (40 cases); Group B: coarctation associated with ventricular septal defect or atrial septal defect (37 cases); Group C: coarctation associated with other complex congenital cardiac lesions (60 cases). The aortic coarctation has been surgically repaired in 73 cases, by using the following techniques: End-to-end anastomosis in 26 patients, Waldhausen repair in 43 and other procedures in the remaining 4 cases. For the surgically treated patients the survival has been: 88% in group A, 90% in group B and 48% in group C. In non-operated patients the survival has been: 21%, 6% and 14%, respectively.

[Enhancing factors in the cardiotoxicity of anthracyclines]. / Factores coadyuvantes de la toxicidad cardiaca por antraciclínicos.

We have studied 60 pediatric patients with different neoplastic diseases, treated with anthracyclines. We have followed them clinically and echocardiographically to detect the cardiotoxicity due to anthracyclines and the enhanced factors promptly. We have detected a more important incidence of cardiomyopathy in patients with non-Hodgkin's lymphoma, osteosarcoma and neuroblastoma despite cumulative doses under 550 mg/m2 of anthracyclines. The 2 first groups were treated with high doses of cyclophosphamide and methotrexate, and neuroblastomas with melphalan. The anthracyclines cardiotoxicity is evaluated around 5% in patients treated with doses under 550 mg/m2, and is increased in case of previous or simultaneous aggressive therapy. Continued echocardiography enables a premature detection of cardiotoxicity in these high risk patients.

[Cardiac complications in Kawasaki disease]. / Complicaciones cardiacas en la enfermedad de Kawasaki.

We present 3 patients, aged 7 and 12 months. and 5 years, who meet the diagnostic criteria for Kawasaki's disease. In these, there was coronary artery involvement. which was identified by two dimensional echocardiography. In two of these, a coronary artery involvement which was identified by two dimensional echocardiography. In two of these, a coronary artery aneurysm was demonstrated within the 3rd week. The aneurysm resolved after 4 months in one patient, and still persist after 15 months in the other. The third patient had a left coronary artery aneurysm, confirmed by angiocardiography, which also showed small aneurysms in the right coronary artery. The electrocardiographic study of this patient, performed 3 months after onset, showed a patterns of necrosis (anterolateral infarction), confirmed by mean of a thallium scintigraphy. We have performed a study about the management of this kind of patients, and can conclude: 1. Coronary angiocardiography may permit the detection of right coronary artery aneurysms, not visualized by echocardiography. 2. Patients with coronary artery aneurysms, with no stenotic lesions 1 the coronary angiocardiography, may evolve into myocardia infarction. 3. We expose our doubts about the indication and right time to perform the angiocardiographic study.