Follow-Up Results of Device Occlusion of Patent Ductus Arteriosus.

BACKGROUND: Transcatheter patent ductus arteriosus (PDA) closure is an established procedure. OBJECTIVES: The aim of the study was to assess midterm follow up of the Nit-Occlud coil and the amplatzer ductal occluder (ADO) closure of PDA. PATIENTS AND METHODS: In this cohort study, we collected the longitudinal data of patients who underwent percutaneous closure using coil or ADO from November 2005 to November 2013. A total of 404 patients with PDA closure by devices were included during the study period. Coil occlusion was performed in 220 patients and 184 patients underwent catheterization using ADO. Follow-up evaluations were performed with echocardiography at two weeks, two months, six months, and during the study period (in average 4.8 ± 3.8 years). RESULTS: The patients' mean age was 24 months (range: 1 - 312). The catheterization was successful in 393 (97.2%) patients and unsuccessful in 11 (2.7%). Immediate complete occlusion was seen in 290 (73.7 %) patients. The occlusion rates at two weeks, two months, six months, and during the study period were 73.7%, 84%, 93.6%, 98.7%, and 99.5%, respectively. Complications occurred in 23 (5.8%) patients during or immediately after the catheterization, and device embolization with 2.7% was the most common complication. Most complications occurred in a patient with pulmonary hypertension who was less than one year old and was undergoing the first year of experience with devices. CONCLUSIONS: Our findings showed that transcatheter occlusion of the PDA is an effective and safe intervention by coil or Amplatzer with excellent early and one-year outcomes. Pulmonary hypertension, age of less than 12 months and experience of less than one year may increase the complications of device closure.

Evaluation of electrocardiographic changes after arterial switch operation.

BACKGROUND: Transposition of Great Arteries (TGA) is a serious congenital heart disease which can be accompanied by good outcomes with anatomic correction within the first few weeks of life. OBJECTIVES: The present study aimed to evaluate electrocardiographic changes in the children with uncomplicated Arterial Switch Operation (ASO). PATIENTS AND METHODS: Twelve lead electrocardiograms were obtained from thirty-three patients with TGA after ASO. Then, the patients' QT-dispersion and P-wave dispersion were compared to those of 33 age- and gender-matched individuals as the normal control group. Both groups were also evaluated by M-mode echocardiography. Student's t-test and Pearson correlation were used to analyze the data. Besides, P < 0.05 was considered as statistically significant. RESULTS: The mean age of the patients and the control group was 41 ± 3.7 and 40.12 ± 4.2 months, respectively. Comparison of P wave, T wave, QRS complex, PR interval, QT segment, and corrected QT segment showed significant differences in the frequency of inverted T wave in pericardial leads [V3, V4, V5, and V6] (P = 0.004; more in patients), P wave amplitude in lead II (P < 0.001; more in patients), R wave amplitude in V1 (P = 0.016; smaller in patients), R and S waves amplitude in V6 (P = 0.004 and P = 0.001; taller in patients), corrected QT segment (in lead V5; P < 0.0001: prolonger in patients), and PR interval (P = 0.001; prolonger in patients). However, no significant differences were found regarding the vector axis and heart rate. Right bundle branch block (18% vs. 0%), Bifascicular (3% vs. 0%), and first-degree blocks (15% vs. 0%) were significantly more in the patients. Besides, the PR interval was longer in the corrected complex TGA (146 ± 24.4 vs. 127.7 ± 23.1, P = 0.001). Moreover, R/S ratio in lead V1 was significantly prolonger, among the patients (2.86 ± 3.35 vs. 0.706 ± 0.53, P = 0.002). Nonetheless, no significant was observed between the patients and controls concerning the mean of QT dispersion. On the other hand, the two groups were significantly difference in terms of P wave dispersion (25.7 ± 13.8 vs. 33.74 ± 12.9, P = 0.024). CONCLUSIONS: In this study, first-degree block and right bundle branch were detected in the operated patients with TGA. Increased P dispersion in these patients may increase the risk of atrial arrhythmia. Thus, long-term follow-up is necessary in these patients.

Effects of omega-3 polyunsaturated Fatty acids on heart function and oxidative stress biomarkers in pediatric patients with dilated cardiomyopathy.

OBJECTIVES: Dilated cardiomyopathy is the most prevalent type of cardiomyopathy in children, which results in congestive heart failure and causes significant morbidity and mortality. This study, aims to investigate the effect of supplementation with omega-3 polyunsaturated fatty acids (n-3 PUFA) on heart function and oxidative stress biomarkers in these patients. METHODS: The present research was a case-control study on pediatric patients with dilated cardiomyopathy, who received n-3 PUFA and anti-failure therapy for 6 months (group 1, n = 6), or anti-failure therapy alone for 6 months (group 2, n = 6), as well as age matched normal individuals (group 3, n = 6), and evaluated the cardiac function and biomarkers of oxidative stress. RESULTS: Echocardiographic parameters, such as left ventricular ejection fraction, shortening fraction, tissue Doppler Ea and Aa waves of lateral annulus of tricuspid valve, and Ea and S wave of septum, were significantly improved in group 1 after n-3 PUFA compared to pre- treatment status, while they were not changed after treatment in group 2. Antioxidant enzymes, including catalase and glutathione peroxidase activities in erythrocytes were slightly decreased, while plasma 8-iso-prostaglandin F2α concentrations were somewhat increased in group 1 compared to groups 2 and 3, however these changes were not statistically significant. Total antioxidant capacity of plasma was similar in all 3 groups. CONCLUSIONS: The results indicate that some echocardiographic parameters were significantly improved in patients receiving omega-3 fish oil. However, omega-3 had no significant effect on oxidative stress biomarkers.

Evaluation of cardiac and valvular function after arterial switch operation: a midterm follow-up.

OBJECTIVES: Transposition of Great Arteries (TGA) is a serious congenital heart disease and anatomic correction in the first few weeks of life has revealed good outcomes nowadays. In this study, we aimed to evaluate the myocardial and valvular function at midterm postoperative follow-up. PATIENTS AND METHODS: In this study, thirty-three patients with TGA and Arterial Switch Operation (ASO) were evaluated by 2-dimensional, M-mode, Doppler, and pulsed Tissue Doppler. These patients were compared with 33 healthy children of the same age and gender as the normal control group. Student's t-test and Pearson correlation were used to analyze the data. Besides, P<0.05 was considered as statistically significant. RESULTS: The mean follow up time was 40.9±5.6 months. Among the 33 patients with ASO, 6% had mild pulmonary stenosis, while 3% had mild pulmonary insufficiency. Aortic stenosis and aortic insufficiency of trivial to mild degree was seen in 12% and 12% of the patients, respectively. The patients' systolic velocity of tricuspid (S), early diastolic velocity of tricuspid (Ea), and late velocity of tricuspid valve (Aa) were significantly different from those of the controls (P<0.001). Also, pulmonary annulus diameter was significantly dilated in the patients compared to the controls (1.67±0.41 vs. 1.29±0.28, P≤0.001). Besides, aortic annulus diameter (1.56±0.42 vs. 1.24±0.21, P=0.001) and also aortic sinus diameter (2.06±0.41 vs. 1.44±0.34, P=0.002) were significantly dilated, while sinutuboar junction diameter (1.65±0.5 vs. 1.28±0.29, P=0.094) was not dilated. Left ventricular function was in the normal range. CONCLUSIONS: This study showed good left ventricular function, but some abnormalities in lateral tricuspid tissue Doppler velocities. Neoaortic and pulmonary diameters were significantly dilated, while aortic and pulmonary insufficiencies were clinically insignificant in most of the patients. Long-term follow-up is necessary in these patients.

Short-term result of ductus arteriosus stent implantation compared with surgically created shunts.

This report aims to compare the researchers' early experience with the safety, efficacy, short-term outcomes, and complications of patent ductus arteriosus (PDA) stents in neonates having duct-dependent pulmonary circulation with those of surgically created shunts. Between April 2009 and April 2011, 18 infants with duct-dependent pulmonary circulation underwent cardiac catheterization for PDA stenting as the first palliative procedure in a referral center. For comparison, 20 infants who underwent surgical aortopulmonary shunt placement in another center were used. Follow-up assessment included clinical examination, echocardiography, oxygen saturation, and cardiac catheterization studies. Access and stenting for the PDA were successful in 15 patients (83.3 %). The mean procedure time was 58.43 ± 41.25 min, and the mean fluoroscopy time was 18.81 ± 5.64 min. Three patients (20 %) in the stented group and 6 patients (30 %) in the surgical group died (P = 0.09). After a 6-month follow-up period, none of the patients had significant stent stenosis requiring reintervention. The oxygen saturation increase did not differ significantly between the two groups either immediately after the procedure or 6 months later (P > 0.5). The left pulmonary artery diameter, McGoon ratio, and Nakata index did not differ significantly between the two groups (P > 0.05), but the right pulmonary diameter was larger in the stented group (5.01 ± 0.45 vs 4.1 ± 0.49 mm; P = 0.0001). Stenting for the PDA is an appropriate alternative to surgical shunt creation in many patients with duct-dependent circulation. In our sample, the two groups did not differ significantly in terms of outcome or mortality.

The prevalence of hypomagnesaemia in pediatric patients with mitral valve prolapse syndrome and the effect of mg therapy.

BACKGROUND: A paucity of data exists regarding the prevalence and relationship of hypomagnesaemia with clinical symptoms of mitral valve prolapse (MVP) in pediatric patients. OBJECTIVE: In this study we evaluated the prevalence of magnesium (Mg) deficiency in pediatric patients with MVP syndrome and attempted to clarify the effect of Mg therapy on alleviating their symptoms. METHODS: The present study was conducted from April 2010 to January 2012, and included 230 patients (90 males and 140 females) with symptoms of mitral valve prolapse and mean age of 11.6±3.66. Serum magnesium (Mg) level less than 1.5 mg/dl was defined as hypomagnesaemia. Patients with 2 mm leaflet displacement and maximum leaflet thickness of 5 mm in echocardiography were considered to have classic MVP, while those with leaflet thickness less than 5 mm were considered as non-classic MVP. Patients with hypomagnesaemia were orally treated with 4.5 mg/kg/day Mg chloride for 5 weeks followed by re-evaluation of symptoms of chest pain, palpitation, fatigue and dyspnea. RESULTS: Hypomagnesaemia was found in 19 (8.2 %) of 230 patients with mitral valve prolapse. The re-evaluation of patients with Hypomagnesaemia after 5 weeks of Mg therapy, showed statistically significant relief of chest pain (P=0.01). However, no significant changes was detected in regard to palpitation (P=0.06), fatigue (P= 0.5) and dyspnea (P=0.99). CONCLUSION: This study revealed that the prevalence of hypomagnesaemia in pediatric patients with mitral valve prolapse is relatively low compared to adults, but treatment with oral Mg in patient with hypomagnesaemia decreases chest pain.

Estimation of Right Atrial Pressure from the Inspiratory Collapse of the Inferior Vena cava in Pediatric Patients.

OBJECTIVE: Paucity of data exists between mean right atrial pressure (RAP) and inferior vena cava (IVC) size and collapsibility in pediatric patients with congenital heart disease. METHODS: In a prospective study, fifty consecutive pediatric patients with different congenital heart diseases who had right side cardiac catheterization were studied, comparing right atrial pressure with simultaneous M-mode echocardiographic measurement of inferior vena cava diameter. Mean age of the patients was 4.96±4.05 years (30 male and 20 female). Patients were categorized into two groups according to their right atrial pressure (RAP) as measured by cardiac catheterization: Group 1 (40 patients) were those with mean RAP <8 mmHg and group 2 (10 patients) who had a mean RAP≥ 8 mmHg. FINDINGS: In M-mode echocardiography IVC size was statistically different (P=0.004 and 0.009) in inspiration and expiration in the two groups. Mean RAP was estimated to be>8 mmHg when IVC diameter in inspiration was >3.6 (sensitivity of 100%, specificity of 47.5%, +LR=1.9) or if IVC diameter was >6mm in expiration (sensitivity of 70%, specificity of 87%, +LR=4.67). CONCLUSION: This study showed that measurement of IVC size in inspiration and expiration can be used as a reliable method for estimation of mean right atrial pressure.

Evaluation of myocardial function by pulsed tissue Doppler in Kawasaki disease.

Myocarditis is a well-recognized component of Kawasaki disease, with left ventricular dysfunction occurring in more than half of patients during the acute phase. The purpose of this study was to evaluate myocardial function in patients with Kawasaki disease using pulsed tissue Doppler imaging (TDI). Twenty-five patients with the diagnosis of acute Kawasaki disease were enrolled in the study. All patients underwent echocardiographic studies at the time of diagnosis of the disease, in its acute phase, prior to treatment, and then 4 weeks later. For an aged-matched control group with fever and no cardiac disease, the same echocardiographic evaluations were performed. Peak velocities of systolic (Sa), early diastolic (Ea), and late diastolic (Aa) motion of the annulus were obtained at the lateral and septal sides in apical four-chamber view, and TDI-derived myocardial performance index (TDI-MPI) was also calculated. Peak Ea velocity of lateral mitral annulus was decreased significantly during the acute phase of illness (14 +/- 4.40 vs. 17.67 +/- 4.41; P = 0.028). In seven patients with carditis, changes in Ea-to-Aa ratio of septum (1.28 +/- 0.278 vs. 1.78 +/- 0.49; P = 0.018) and lateral mitral annulus (1.23 +/- 0.496 vs. 2.11 +/- 0.822; P = 0.014) were statistically significant but TDI-MPI showed no statistically significant changes. This study showed that peak mitral annular Ea velocities obtained by TDI were significantly altered in the acute phase of Kawasaki disease. TDI- MPI does not add an incremental benefit to other indexes of myocardial performance for comprehensive myocardial function in the acute phase of Kawasaki disease.

Detection of pulsus paradoxus by pulse oximetry in pediatric patients after cardiac surgery.

The presence or absence of pulsus paradoxus (PP), defined as an inspiratory decrease greater than 10 mmHg in systolic blood pressure, can have significant diagnostic and therapeutic implications for many clinical conditions including acute asthma, pericardial tamponade, heart failure, hypovolemia, shock states, and the like. However, PP may be difficult to measure in children. Indwelling arterial catheters facilitate the measurement of PP, but this invasive technique generally is reserved for critically ill patients. This study aimed to assess the use of the pulse oximetry plethysmographic waveform (POPW) for the detection of PP in pediatric patients after cardiac surgery. The study enrolled 40 pediatric patients 18 years of age and younger who had invasive blood pressure monitoring with an intraarterial cannula. Systolic pressure variability (SPV) and changes in POPW amplitude (DeltaPOPW%), calculated using five consecutive snapshots from every patient's monitor, were compared using linear regression, Pearson product-moment correlation, the Spearman rank method, and receiver operating characteristic (ROC) curve analysis. A strong correlation existed between respiratory SPV and DeltaPOPW% for the detection of PP (r = 0.682; p < 0.0001). A respiratory variation in DeltaPOPW% exceeding 25.44% (about one-fourth the amplitude of the tallest POP waveform) allowed detection of PP with a sensitivity of 86.7% and a specificity of 88%. Pulse oximetry is a readily available and easily performed noninvasive means for detecting PP in children.

A wandering stent in the ascending aorta.

A 15-year-old girl underwent patch aortoplasty for repair of a long-segment coarctation of the aorta 7 years ago. Balloon angioplasty had been performed twice, 3 and 5 years after the aortoplasty, because of recurrent coarctation of the aorta. She was scheduled for balloon angioplasty and stent implantation. In catheterization, there was 55 mmHg gradient between ascending and descending aorta and the angiography showed long-segment coarctation of the aorta, from the transverse aorta, after the innominate artery, to the descending aorta, after the left subclavian artery. During the final pressure measurement, in the catheterization laboratory, the stent was dislodged proximally and trial for reimplantation or retrieval failed. Echocardiography showed the trapped stent in the ascending aorta. She was taken to the operating room, where the stent was removed and the aortic arch was reconstructed from the innominate artery to the distal part of the subclavian artery, using a Dacron patch.

Preload dependence of Doppler tissue imaging-derived indices in adolescents.

Doppler tissue imaging (DTI) has been proposed as a tool for evaluation of diastolic function. Controversy exists regarding whether DTI measurements are influenced by preload. To determine the influence of preload reduction on DTI, we studied 17 patients (mean age 17 +/- 1.82 years) with end-stage renal disease and without overt heart disease, using DTI before and after hemodialysis (HD). Peak systolic (S), peak early diastolic (Ea), and peak late diastolic (Aa) velocities, and tissue Doppler-derived Tei index (the sum of the isovolumetric contraction and relaxation times divided by the ejection time: TDE-Tei), were determined for each patient from the septum, and lateral mitral and lateral tricuspid annuluses. The Ea of the mitral annulus (12.47 +/- 4.51 cm/s to 10.71 +/- 5.18 cm/s, P = 0.023), isovolumetric contraction time (ICT) of the mitral annulus (85.29 +/- 33.66 ms to 68.76 +/- 17.24 ms, P = 0.031) and Aa of the lateral tricuspid annulus (15.94 +/- 6.46 cm/s to 12.47 +/- 3.85 cm/s, P = 0.044) decreased significantly after HD. With weight loss of more than 1.5 kg, significant changes in the TDE-Tei index of the septum was observed (P = 0.036). From these findings, it is concluded that the Ea of the mitral annulus and the Aa of the tricuspid annulus are decreased by acute preload reduction. The TDE-Tei index is affected by preload reduction of more than 1.5 kg; therefore, it seems necessary to consider the preload status of HD patients when myocardial function is assessed by DTI.

Comparison of the effectiveness of oral sildenafil versus oxygen administration as a test for feasibility of operation for patients with secondary pulmonary arterial hypertension.

It is shown that phosphodiesterase type 5 (PDE5) inhibitors such as sildenafil can modulate pulmonary arterial hypertension (PAH) via increasing the level of guanosine-3,5-cyclic monophosphate (cGMP) and decreases pulmonary artery pressure (PAP). In this study we determined the effectiveness of sildenafil and compared its efficacy with inhaled nasal oxygen (O2) during cardiac catheterization in patients with congenital heart diseases (CHD) and PAH, as a test of feasibility for surgical repair of the patients. We studied 15 patients, 9 male and 6 female, with a mean age of 8.3 years. Hemodynamic measurements were made at baseline, after O2 administration for 20 min (5 L/min by mask), and then 45 min after administration of a single dose of sildenafil (0.5 mg/kg orally or via nasogastric tube). Mean PAP at baseline was 72.2 +/- 12.54 mm Hg and was reduced by sildenafil to 52.5 +/- 9.6 and by O2 to 61.3 +/- 10.39. Both sildenafil and O2 decreased PAP effectively (p = 0.08 and p = 0.04, respectively). Pulmonary vascular resistance (PVR) was calculated for 12 patients, with a baseline level of 9.08 +/- 1.09 mm Hg . L(-1) . min, which was significantly decreased by O2, to 3.74 +/- 0.43, and by sildenafil, to 5.93 +/- 0.75 (p = 0.005 and p = 0.05, respectively). Sildenafil, as a single oral dose, can effectively reduce PAP and PVR. This novel PDE5 inhibitor can be used for assessment of feasibility of operation for patients with CHD and PAH when inhaled NO is not available.

The experience with 113 patients with Kawasaki disease in Fars Province, Iran.

This study was conducted to determine the epidemiology, clinical manifestations, cardiac involvements and laboratory findings of Kawasaki disease (KD) in Fars Province, Iran from January 1991 to December 2002. One hundred and thirteen patients with KD were confirmed. This syndrome occurred mostly in males (ratio=2.1:1). The most commonly affected age group was one to five years old. There was no secondary case in families, none of the patients were related and recurrence of disease was seen in only one patient. Prolonged fever and thrombocytosis were significant risk factors for developing coronary artery disease (p<0.05, respectively). Among the 10 patients with cardiac involvement, seven patients had dilated coronary arteries (>4 mm) and three patients had aneurysm of coronary artery in their first echocardiography. It has been suggested that a high index of clinical suspicion of KD could improve diagnosis and implementation of preventive treatment.