Calidad de la coronariografía 3D por resonancia magnética en los pacientes con D-transposición de las grandes arterias intervenidos con switch arterial de Jatene / Quality of 3D magnetic resonance imaging of coronary arteries in patients with D-transposition of the great arteries after the Jatene switch procedure

Objetivos. Valorar la calidad de imagen de la secuencia 3D de todo el corazón (3D balanced fast field echo, whole heart [WH3D]) para estudiar la anastomosis coronaria y las estenosis coronarias en los pacientes con D-transposición de las grandes arterias intervenidos con switch arterial de Jatene. Material y métodos. Rescatamos de la base de datos de RM cardiaca pediátrica 100 exploraciones en 83 pacientes intervenidos con la técnica de Jatene y secuencia WH3D. Cumplían criterios de inclusión en el estudio 84 exploraciones. Valoramos las estenosis coronarias mediante WH3D y su correlación con la TC coronaria o la angiografía por catéter. Estudiamos retrospectivamente la calidad de la imagen de las arterias coronarias proximales con una escala de 4 puntos y la correlación con la edad, frecuencia cardiaca y tamaño cardiaco. Resultados. Cuatro de los 84 estudios (4,8%) mostraron calidad «insuficiente» para el diagnóstico, 7 (8,3%) «discreta», 23 (27,4%) «buena» y 50 (59,5%) «excelente». La frecuencia cardiaca y la calidad de la imagen coronaria se relacionaron estadísticamente. Con la RM detectamos estenosis en el origen coronario en 9 exploraciones (10,7%). Conclusión. La calidad de imagen con la secuencia WH3D fue diagnóstica en la mayoría de los pacientes intervenidos con la técnica de Jatene, mejor en pacientes con menor frecuencia cardiaca. En el 10,7% se diagnosticó una estenosis del origen coronario que obligó a nuevas exploraciones (AU)

Objectives. To evaluate the quality of images obtained with 3D balanced fast-field echo whole heart (WH3D) MRI sequences for assessing the coronary anastomosis and coronary stenosis in patients with D-transposition of the great arteries who have undergone the Jatene switch procedure. Material and methods. We retrieved 100 WH3D studies done in 83 patients who had undergone the Jatene switch procedure from our pediatric cardiac MRI database; 84 of these studies fulfilled the criteria for inclusion in the study. We evaluated coronary stenoses on WH3D MR images and their correlation with coronary CT or angiography images. We retrospectively studied the quality of the images of the proximal coronary arteries using a four-point scale and correlating the findings with age, heart rate, and heart size. Results. Of the 84 studies, 4 (4.8%) were of a quality considered «insufficient for diagnosis», 7 (8.3%) were considered «fair», 23 (27.4%) «good», and 50 (59.5%) «excellent». The quality of the image of the coronary arteries was significantly correlated with heart rate. MRI detected stenosis in the origin of the coronary arteries in 9 (10.7%) studies. Conclusion. Images obtained with the WH3D MRI sequence in patients who had undergone the Jatene procedure were of diagnostic quality in most cases and were better in patients with lower heart rates. In 10.7%, stenosis in the origin of the coronary arteries that required new studies was detected (AU)

[Quality of 3D magnetic resonance imaging of coronary arteries in patients with D-transposition of the great arteries after the Jatene switch procedure]. / Calidad de la coronariografía 3D por resonancia magnética en los pacientes con D-transposición de las grandes arterias intervenidos con switch arterial de Jatene.

OBJECTIVES: To evaluate the quality of images obtained with 3D balanced fast-field echo whole heart (WH3D) MRI sequences for assessing the coronary anastomosis and coronary stenosis in patients with D-transposition of the great arteries who have undergone the Jatene switch procedure. MATERIAL AND METHODS: We retrieved 100 WH3D studies done in 83 patients who had undergone the Jatene switch procedure from our pediatric cardiac MRI database; 84 of these studies fulfilled the criteria for inclusion in the study. We evaluated coronary stenoses on WH3D MR images and their correlation with coronary CT or angiography images. We retrospectively studied the quality of the images of the proximal coronary arteries using a four-point scale and correlating the findings with age, heart rate, and heart size. RESULTS: Of the 84 studies, 4 (4.8%) were of a quality considered «insufficient for diagnosis¼, 7 (8.3%) were considered «fair¼, 23 (27.4%) «good¼, and 50 (59.5%) «excellent¼. The quality of the image of the coronary arteries was significantly correlated with heart rate. MRI detected stenosis in the origin of the coronary arteries in 9 (10.7%) studies. CONCLUSION: Images obtained with the WH3D MRI sequence in patients who had undergone the Jatene procedure were of diagnostic quality in most cases and were better in patients with lower heart rates. In 10.7%, stenosis in the origin of the coronary arteries that required new studies was detected.

Cardiología Fetal / Fetal cardiology

La ecocardiografía fetal ofrece una ventana al corazón fetal que no solo ha permitido una mejora en el diagnóstico prenatal de las cardiopatías congénitas (CC), sino que ayuda a entender la evolución y desarrollo de las malformaciones cardíacas y la repercusión de determinadas enfermedades extracardíacas sobre el sistema cardiovascular en desarrollo. Las cardiopatías congénitas son las malformaciones fetales más frecuentes, con una incidencia general de 4-8/1.000 recién nacido vivo, y son responsables del 20% de las muertes neonatales y del 50% de las muertes infantiles. Las malformaciones cardíacas son los defectos más frecuentemente pasados por alto en la valoración prenatal. Esto se debe a que es una técnica compleja y operador-dependiente que precisa de un entrenamiento específico y tiempo para realizar una exploración adecuada. El cuidado y manejo de estos pacientes precisa de un equipo multidisciplinar con cardiólogos infantiles especializados en cardiología fetal, obstetras y ecografistas obstétricos, genetistas, psicólogos y trabajadores sociales para poder ofrecer una valoración completa y cuidado integral del feto y de sus padres (AU)

Fetal echocardiography offers a window to the fetal heart that has not only allowed for an improvement in prenatal diagnosis of congenital heart disease (CHD) but also helps to understand the evolution and development of cardiac malformations and the repercussion of certain extracardiac diseases on the developing cardiovascular system. Congenital heart diseases are the most frequent fetal malformations having a general incidence of 4-8/1000 live newborns. They are responsible for 20% of neonatal deaths and 50% of child deaths. Cardiac malformations of the most frequently overlooked defects in the prenatal evaluation. This is because the fetal echocardiography is a complex and operator-dependent technique that requires specific training and time to carry out an adequate examination. The care and management of these patients require a multidisciplinary team with child cardiologist specialized in fetal cardiology as well as obstetricians and obstetric ultrasonographists, geneticist, psychologist and social workers in order to offer a complete evaluation and comprehensive care of the fetus and parents (AU)

Consenso clínico sobre la profilaxis de la infección por virus respiratorio sincitial y el uso del palivizumab en cardiología pediátrica / Clinical consensus on respiratory syncytial virus (RSV) infection prophylaxis and the use of palivizumab in paediatric cardiology

Antecedentes: Tras la finalización y análisis de resultados del estudio CIVIC, la Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas (SECPCC) plantea la necesidad de revisar sus recomendaciones para la prevención del VRS en niños con cardiopatías congénitas. Para considerar tanto la valoración de las nuevas evidencias disponibles como la experiencia preventiva acumulada por los cardiólogos infantiles, se propone efectuar dicha actualización mediante un método estructurado de consenso profesional. Objetivos: Desarrollar un consenso clínico español sobre la prevención de la infección por virus respiratorio sincitial, bajo el auspicio de la Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas. Métodos: Consenso Delphi modificado en 2 rondas. El estudio se efectuó en 4 fases: 1) constitución de un comité científico, impulsor del proyecto y responsable de la revisión bibliográfica y de la formulación de las recomendaciones a debate; 2) constitución de un panel experto multicéntrico con 75 representantes de la especialidad; 3) encuesta postal en 2 rondas con procesamiento intermedio de opiniones e informe a los panelistas, y 4) discusión de resultados en sesión presencial del comité científico. Resultados: Cincuenta y cinco expertos consultados completaron las 2 rondas de evaluación del cuestionario. En la primera ronda se lograron consensuar 44 de las 70 cuestiones analizadas. Tras la interacción del panel, se aumentó el consenso hasta un total de 54 ítems de la encuesta (el 77% de los contenidos propuestos). En las 16 cuestiones restantes no se consiguió un consenso suficientemente unánime, bien por disparidad de opiniones entre los profesionales, bien por falta de criterio establecido en la mayoría de los expertos. Conclusiones: Se presenta y actualiza una lista de recomendaciones profilácticas frente al virus respiratorio sincitial, cualificadas según el grado de acuerdo profesional en que se sustentan, que pueden considerarse vigentes hasta la aparición de nueva información científica que justifique su revisión (AU)

Background: Following the results of the CIVIC study, the SECPCC proposes to revise its recommendations for the prevention of RSV, taking into account the new evidence, as well as the preventive experience of paediatric cardiologists. For this purpose a structured method of professional consensus has been chosen. Objectives: To develop a Spanish clinical consensus on preventing infection by RSV under the auspices of the Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas. Methods: Delphi Consensus modified in two rounds. The study was conducted in four phases: 1) constitution of a Scientific Committee for bibliographic review and submission of the recommendations for discussion, 2) constitution of an Expert Panel with 75 representatives in the speciality, 3) postal survey organised in two rounds and intermediate processing of opinions, and issuing of a report to the panellists, and 4) discussion of the results in a face-to-face meeting of the Scientific Committee. Results: Consensus was reached on 54 of the 70 preventive recommendations analysed. With respect to the 16 remaining issues, no consensus was reached, due to differences in professional opinion and the absence of established criteria among the majority of the experts. Conclusions: A set of recommendations for RSV prophylaxis in cardiology was developed and updated, rated in accordance with the degree of professional consensus on which they were based. These can be considered valid until such time as new scientific information emerges that warrants a further review (AU)

[Clinical consensus on respiratory syncytial virus (RSV) infection prophylaxis and the use of palivizumab in paediatric cardiology.]. / Consenso clínico sobre la profilaxis de la infección por virus respiratorio sincitial y el uso del palivizumab en cardiología pediátrica.

BACKGROUND: Following the results of the CIVIC study, the SECPCC proposes to revise its recommendations for the prevention of RSV, taking into account the new evidence, as well as the preventive experience of paediatric cardiologists. For this purpose a structured method of professional consensus has been chosen. OBJECTIVES: To develop a Spanish clinical consensus on preventing infection by RSV under the auspices of the Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas. METHODS: Delphi Consensus modified in two rounds. The study was conducted in four phases: 1) constitution of a Scientific Committee for bibliographic review and submission of the recommendations for discussion, 2) constitution of an Expert Panel with 75 representatives in the speciality, 3) postal survey organised in two rounds and intermediate processing of opinions, and issuing of a report to the panellists, and 4) discussion of the results in a face-to-face meeting of the Scientific Committee. RESULTS: Consensus was reached on 54 of the 70 preventive recommendations analysed. With respect to the 16 remaining issues, no consensus was reached, due to differences in professional opinion and the absence of established criteria among the majority of the experts. CONCLUSIONS: A set of recommendations for RSV prophylaxis in cardiology was developed and updated, rated in accordance with the degree of professional consensus on which they were based. These can be considered valid until such time as new scientific information emerges that warrants a further review.

Ausencia de realce tardío por resonancia magnética en la no compactación del ventrículo izquierdo en lactantes y niños pequeños / Lack of MR late-enhancement in left ventricular non-compaction in infants and young children

Objetivo: La miocardiopatía no compactada o la no compactación del ventrículo izquierdo (NCVI) es una enfermedad rara y probablemente infradiagnosticada. El diagnóstico es ecográfico, si bien la resonancia magnética (RM) aporta importante información morfológica y funcional. El realce tardío es un hallazgo importante que refleja fibrosis o infarto en las zonas afectadas, y se refiere en adultos y niños mayores de forma generalizada. El objetivo de este trabajo es revisar el realce tardío en esta enfermedad en lactantes y niños pequeños. Material y métodos: En nuestra base de datos de RM cardíaca encontramos 5 pacientes (rango de edad: un mes a 5 años; media de 29,4 meses). Se revisaron los hallazgos morfológicos y funcionales, incluyendo el realce tardío de contraste. Resultados: Todos los pacientes se diagnosticaron previamente por ecocardiografía. Los hallazgos morfológicos y el cociente miocardio no compactado/miocardio compactado fueron compatibles con NCVI. Ninguno de los casos mostró realce tardío poscontraste. Conclusiones: Al contrario que en adultos y niños mayores, ninguno de nuestros pacientes mostró realce tardío. Este hallazgo podría reflejar la naturaleza evolutiva de la fibrosis subendocárdica en estos pacientes (AU)

Objective: Non compaction cardiomyopathy or left ventricular non compaction is a rare disease that is probably underdiagnosed. The diagnosis is reached by echocardiography, although MRI provides additional morphological and functional information. Late MRI enhancement is a hallmark of the disease that reflects fibrosis or infarction of affected areas in adults and older children. We aimed to review the presence of late enhancement in left ventricular non compaction in infants and young children. Material and methods: We found five very young patients (mean age, 29.4 months; range 1 month to 5 years) with left ventricular non compaction in our cardiac MRI database. We reviewed the morphological and functional findings, including late enhancement after the administration of contrast material. Results: All patients had been previously diagnosed by echocardiography. At MRI, the morphological findings and the ratio of non compacted myocardium to compacted myocardium were compatible with left ventricular non compaction. None of the cases showed late enhancement after the administration of contrast material. Conclusions: Unlike in adults and older children, none of the infants and young children we studied had late enhancement. This finding might reflect the natural history of the disease, with subendocardial fibrosis developing over time (AU)

[Lack of MR late-enhancement in left ventricular non-compaction in infants and young children]. / Ausencia de realce tardío por resonancia magnética en la no compactación del ventrículo izquierdo en lactantes y niños pequeños.

OBJECTIVE: Noncompaction cardiomyopathy or left ventricular noncompaction is a rare disease that is probably underdiagnosed. The diagnosis is reached by echocardiography, although MRI provides additional morphological and functional information. Late MRI enhancement is a hallmark of the disease that reflects fibrosis or infarction of affected areas in adults and older children. We aimed to review the presence of late enhancement in left ventricular noncompaction in infants and young children. MATERIAL AND METHODS: We found five very young patients (mean age, 29.4 months; range 1 month to 5 years) with left ventricular noncompaction in our cardiac MRI database. We reviewed the morphological and functional findings, including late enhancement after the administration of contrast material. RESULTS: All patients had been previously diagnosed by echocardiography. At MRI, the morphological findings and the ratio of noncompacted myocardium to compacted myocardium were compatible with left ventricular noncompaction. None of the cases showed late enhancement after the administration of contrast material. CONCLUSIONS: Unlike in adults and older children, none of the infants and young children we studied had late enhancement. This finding might reflect the natural history of the disease, with subendocardial fibrosis developing over time.

Angiografía con contraste por resonancia magnética en las cardiopatías congénitas / Contrast-enhanced magnetic resonance angiography in congenital heart disease

El avance de la resonancia magnética (RM) de cuerpo ha visto en la angiografía con contraste por RM (ACRM) uno de sus mayores logros. La evaluación no invasiva de arterias y venas evita la realización de cateterismo, la administración de contraste yodado y la exposición a radiaciones ionizantes a un gran número de pacientes. Este hecho es, si cabe, de mayor relevancia en los niños con cardiopatías congénitas, al tratarse de pacientes a los que habrá que realizar numerosos estudios vasculares a lo largo de su vida, con los riesgos inherentes del cateterismo, los debidos al contraste yodado, y la mayor susceptibilidad de estos pacientes a los efectos de las radiaciones ionizantes. La ACRM aporta abundante información para el diagnóstico y seguimiento posquirúrgico en este grupo de pacientes que, con los avances terapéuticos médicos y quirúrgicos, hoy en día alcanzan edades avanzadas y reciben, cada vez más, numerosos estudios de imagen a lo largo de su vida. En esta revisión se analiza la técnica de la ACRM en estos pacientes, los problemas y precauciones relativas al uso del gadolinio, las indicaciones y los hallazgos radiológicos a los que hay que prestar especial atención en esta patología (AU)

Contrast-enhanced MR angiography is one of the greatest achievements brought about byadvances in body MRI. The non invasive evaluation of arteries and veins can obviate heartcatheterization, the administration of iodinated contrast, and exposure to ionizingradiation in many patients and spare them the risks associated with these factors. These gains are even more important in children with congenital heart disease, who will have toundergo numerous vascular studies in their life times and are more susceptible to theeffects of ionizing radiation. Contrast-enhanced MR angiography provides abundantinformation for diagnosis and postoperative follow-up in these patients, who reachadvanced age thanks to advances in medical and surgical treatment and thus receive moreand more imaging studies during their life times. In this review, we analyze the contrast-enhanced MR angiography technique in these patients, the problems and precautionsrelated to the use of gadolinium, the indications for the test, and the relevant imagingfindings in patients with congenital heart disease (AU)

Resultados a medio plazo del cierre percutáneo de la comunicación interauricular en niños / Medium-term results of percutaneous closure of atrial septal defect

Objetivo: Evaluar los resultados a medio plazo del cierre percutáneo de la comunicación interauricular (CIA). Métodos: Bajo anestesia general se procedió por vía anterógrada al intento de cierre percutáneo de la CIA tipo ostium secundum en 22 niños. La edad fue de 5,7 ± 2, 4 años y el peso 23 ± 11kg. El procedimiento se monitorizó mediante ecocardiografía transesofágica (ETE). Los dispositivos utilizados fueron DAS-Angel Wings(r) y Amplatzer(r). Resultados: Hemodinámicos: presión arterial pulmonar 13 ± 2,8 mmHg, resistencias pulmonares, 1,3 ± 0,3U/m2 y Qp/Qs 2,2 ± 0,6. El diámetro del defecto por ETE fue de 14,5 ± 6,3 mm y por oclusión con balón de 15,9m2 5,3mm. Se emplearon 31 dispositivos, 27 Amplatzer(r) y 4DAS-Angel Wings(r). Se retiraron sin dificultad 12 dispositivos Amplatzer(r)a través de su introductor, cinco por discrepancia con el tamaño de la aurícula izquierda, cuatro por no estabilizarse en el tabique al ser demasiado pequeños y tres por apertura defectuosa en la aurícula izquierda. En 19 pacientes el dispositivo se implantó de forma correcta. La ecocardiografía transtorácica con Doppler color realizada a las 24h demostró ausencia de cortocircuito 17 y en todos al mes de la implantación. Los niños fueron dados de alta a las 38 ± 12h y en el seguimiento de 15 ± 6meses no se han producido complicaciones, fracturas de la estructura, ni se han demostrado cortocircuitos residuales. Conclusión: Mediante cierre percutáneo se consiguió una elevada tasa de cierre sin cortocircuito residual cuando se realizó una adecuada selección de los pacientes (AU)

[Mid-term results of percutaneous closure of atrial septal defect in children]. / Resultados a medio plazo del cierre percutáneo de la comunicación interauricular en niños.

OBJECTIVE: To evaluate the medium-term results of percutaneous closure of atrial septal defect. METHODS: Twenty-two children (mean weight, 23 11kg; mean age, 5.7 2.4 years) underwent percutaneous atrial septal defect closure under general anesthesia. The procedure was monitored by transesophageal echocardiography. DAS-Angel Wings (n4) and the Amplatzer device (n18) were used. RESULTS: Mean pulmonary artery pressure was 13 2.8mmHg, mean pulmonary vascular resistance was 1.50.5U/m2 and mean Qp/Qs flow ratio was 2.2 0.6. The mean diameter of the defects was 14.5 6.3mm by transesophageal echocardiography OmniPlane measurement and 15.95.3mm using balloon occlusion reference. A total of 31 devices were used: 4 Angel Wings and 27Amplatzer devices. Twelve Amplatzer devices were withdrawn through the introducer without complications, 5 due to a discrepancy in the size of the left auricle, 4 because they were too small to stabilize in the septum and 3 due to defective opening in the left auricle. In 19 patients implantation was successful. In 17 patients transthoracic color Doppler echocardiography carried out 24 hours after the procedure showed a minimal shunt which was no longer present 1 month later. The mean time of discharge was 38 12 hours after the procedure. After a mean follow up 15 6 months the patients remain asymptomatic with no clinical or technical problems. CONCLUSION: The success rate of percutaneous closure of atrial septal defects in well-selected patients was high and presented no complications.

[Percutaneous closure of atrial septal defects: midterm results of a new therapeutic strategy]. / Cierre percutáneo de la comunicación interauricular: resultados a medio plazo de esta nueva opción terapéutica.

OBJECTIVE: To evaluate the midterm results of percutaneous closure of the atrial septal defect using two new devices. PATIENTS AND METHODS: Nine children (weight 19.7 +/- 7 kg, age 5.1 +/- 1.9 years) underwent percutaneous type II atrial septal defect closure through the antegrade pathway under general anaesthesia, and monitored by transesophageal echocardiography. The closing devices used were DAS-Angel Wings and Ampaltzer. RESULTS: The hemodynamic results were: mean diameter of the defects was 11.4 +/- 2 mm by TEE measurement and 12.3 +/- 2.6 mm using balloon occlusion reference. Mean pulmonary artery pressure was 12.7 +/- 2 mmHg and mean pulmonary vascular resistance 1.5 +/- 0.5 U/m2. A total of 13 devices were used: 9 Amplatzer and 4 DAS-Angel Wings. Four Amplatzer through the introducer were retrieved without complications. Two of which because of lack of sufficient stability in the atrial septum because they were too small inappropriate and the other two because of inappropriate expansion of distal disk of the device. Finally in all patients the device was a successfully deployed. The angiographic evaluation immediate post-procedure showed a minimal shunt in five patients that was no longer present by color Doppler echocardiography 24 hours later. The children were discharged 38 +/- 12 hours after the procedure and at a mean follow up of 9.6 +/- 2.2 months they remain asymptomatic without any clinical or technical problems. CONCLUSION: With the right selection of patients percutaneous closure of atrial septal defects can obtain a very high success rate without complications.

Alternativas terapéuticas de la miocardiopatía dilatada idiopática en la edad pediátrica / Therapeutic alternatives for the management of idiopathic dilated cardiomyopathy

La miocardiopatía dilatada idiopática es la afectación cardiaca con disfunción sistólica más frecuente en la infancia. Aunque su causa es desconocida, la mayoría de los autores acepta que se trata del estadio final evolutivo de una miocarditis vírica aguda o subaguda. En este artículo se recogen las alternativas terapéuticas de este proceso: tratamiento de la insuficiencia cardiaca, inmunoterapia y trasplante cardiaco, señalando la experiencia de la Sección de Cardiología Pediátrica del HGU 'Gregorio Marañón' en algunas de estas opciones terapéuticas (AU)

Estado actual del cateterismo cardiaco en pediatría / Pediatric cardiac catheterization: state of the art

En los últimos años se han producido importantes avances en el cateterismo cardiaco en niños. El desarrollo de otras técnicas de imagen como la ecocardiografía y la resonancia magnética nuclear han sustituido al cateterismo diagnóstico en muchos casos, mientras que las técnicas invasivos son cada vez más frecuentes. En el HGU 'Gregorio Marañón' se han practicado en los últimos diez años 1.436 cateterismos cardiacos en niños, de los que 338 fueron terapéuticos, y 243 biopsias endomiocárdicas. Se presentan las indicaciones, contraindicaciones y complicaciones del cateterismo cardiaco diagnóstico. Asimismo se exponen los diferentes procedimientos intervencionistas, incluyendo las últimas técnicas como el cierre percutáneo de la comunicación interauricular. Es de esperar que materiales y técnicas mejoren en los próximos años permitiendo extender sus aplicaciones a numerosos pacientes (AU)

Diagnóstico y tratamiento de la estenosis aórtica valvular en niños / Pediatric aortic valve stenosis: diagnosis and treatment

La estenosis aórtica congénita es una cardiopatía frecuente que condiciona la actividad cotidiana del niño y del adolescente. Se discuten las técnicas diagnósticas necesarias en el seguimiento de esta enfermedad en los distintos grupos de edad pediátricos, así como la historia natural. La mayoría de estos pacientes precisa siempre cierto grado de restricción de su actividad física y de su práctica deportiva debido al riesgo de muerte súbita y síncope. El tratamiento actual de la estenosis aórtica valvular en la edad Pediátrica es la valvuloplastia con catéter balón, que ha demostrado resultados superiores a las técnicas quirúrgicas. Siempre que sea posible debe evitarse el recambio valvular en niños, debido a la duración limitada de las prótesis y la necesidad de anticoagulación (AU)

[Extracorporeal membrane oxygenation, ECMO. Experience with the first 22 cases]. / Oxigenación por membrana extracorpórea, ECMO. Experiencia de los primeros 22 casos.

OBJECTIVE: Extracorporal membrane oxygenation (ECMO) is an alternative to cases of respiratory or cardiopulmonary insufficiency when conventional therapy has failed. We present the first 22 patients treated with ECMO at the neonatology unit of the "Gregorio Marañon" Hospital. PATIENTS AND METHODS: From October 1997 until September 1999, 22 patients were treated with ECMO. In 8 of them ECMO was necessary because of respiratory insufficiency without response to conventional treatment (r-ECMO) and a veno-venous tidal flow system was used. In 14 patients, cardiac ECMO was necessary in the veno-arterial modality because of ventricular failure after extracorporal circulatory assistance during cardiovascular surgery. RESULTS: The 8 patients of the respiratory ECMO group had a mean previous oxygenation index of 89 +/- 36.6 (50-150). The mean duration of ECMO was 7.8 +/- 6.5 (1-16) days and the age at the beginning of ECMO ranged between 1 and 151 days. The most frequent indications in this group were congenital diaphragmatic hernia in three cases, meconium aspiration syndrome in 2 cases and 1 case each of septic shock, idiopathic pulmonary hypertension and air leak. The cannula was removed in 5/8 patients due to recovery and 5/8 survived. The 14 patients of the cardiac ECMO group needed veno-arterial ECMO because of severe ventricular failure. Eight out of fourteen were decannulated after improvement. In 5/14 there was multiorgan failure or bad neurological prognosis resulting in death while on ECMO. In 1 out of 14 patients removal of the cannula was impossible because of cardiac insufficiency. The mean age at the beginning of ECMO was 54 (3-178) days. The mean weight at ECMO was 3209 +/- 739 (2700-5000) gr and the mean duration of ECMO was 6 (1-15) days. CONCLUSIONS: ECMO is an effective treatment in rescuing critical patients when conventional treatment fails. Meconium aspiration syndrome is the pathology with the best prognosis on ECMO. Cardiac ECMO represents a complex group of patients in which ECMO is the only treatment and which may result in recovery in 40% of the patients.

[The midterm evolution in the percutaneous closure of ductus arteriosus with the Rashkind prosthesis]. / Evolución a medio plazo del cierre percutáneo del ductus arterioso mediante la prótesis de Rashkind.

Background percutaneous PDA occlusion has been proposed as a valid therapeutic alternative to surgical closure. Between April 1990 and July 1994, 44 patients underwent percutaneous PDA occlusion. Thirteen patients were less than 18 months old and weighed 8.7 +/- 3.2 Kg (Group I). Thirty-one patients, older than 18 months of age, had a mean weight of 36.8 +/- 20.6 Kg (Group II). Four patients in group I and two in group II had associated cardiac anomalies Residual shunt after percutaneous occlusion was studied by color Doppler. Fifty-one occluding devices were used. Forty-nine were implanted and there were two device embolizations. Twelve devices were implanted in group I. One device needed surgical removal from the right ventricle where it had embolized. In group II, 31 devices were implanted and one embolized to the descending aorta and was percutaneously removed through the femoral artery sheath. In two patients of group I and four of group II, a second device was implanted. The total occlusion rate immediately after implantation at 24 hours and at 6 months was 75%, 83% and 83% in group I and 64.5%, 77% and 84% in group II. After implantation of a second device the total occlusion rate without residual shunt reached 100% in group I (after 16 +/- 12 months follow-up) and 97% in group II (after 23 +/- 16 months of follow-up). We conclude that percutaneous ductal occlusion with a Rashkind device is a valid therapeutic alternative to surgical closure in all age groups.

[Outcome of anatomical correction of transposition of the great vessels in the neonatal period]. / Resultados de la corrección anatómica en la transposición de las grandes arterias en el periodo neonatal.

Between february 1992 to January 1994, anatomic correction was performed on 15 patients with transposition of the great arteries and intact ventricular septum. The mean age was 8.3 +/- 2.9 days and the mean weight 3.39 +/- 0.39 Kg. Before the operation, 13 patients (86.6%) received prostaglandin El infusion and 13 patients (86.6%) underwent Rashkind septostomy. Mean aortic cross-clamps was 56 +/- 11 minutes and mean cardiopulmonary bypass was 108 +/- 91 minutes. Hospital mortality rate was 13%. Mean extubation period was mean discharge from ICU was 13.1 +/- 12.3 days and discharge of hospital was 17.8 +/- 7.5 days. The mean followup period was 11.4 months. All the patients remained asymptomatic with adequate psychomotor and ponderal development. All patients remained in sinus rhythm. Pulmonary suture gradient was over 60 mm Hg in five patients (33%). One patient needed reintervention and four pulmonary artery angioplasty (PAA) that was successful. In the midterm follow-up pulmonary stenosis suture was the most common complication. If the stenosis is severe and PAA should be the initial approach.