Clinical characteristics, imaging findings, management, and outcomes of patients with scimitar syndrome at a tertiary referral healthcare center in Colombia.

Scimitar Syndrome is part of a complex spectrum of congenital cardiovascular anomalies related to anomalous pulmonary venous return. Depending on the extent of involvement, treatment can be either expectant or surgical. Prognosis and survival have been controversial, with some results supporting early surgical management. This research aims to disclose the outcomes and describe the management, clinical and imaging characteristics of patients diagnosed with Scimitar Syndrome treated in a tertiary referral healthcare center. Longitudinal descriptive observational study. The study included all patients diagnosed with scimitar syndrome in our institution between January/2011 and December/2022. A description of the sociodemographic and clinical characteristics, diagnostic tools used, treatment features, and patient outcomes is provided. Eleven patients were included, with a mean age at diagnosis of five years (CI 0-17), six of which were female (54.55%). Nine (81.82%) patients had evidence of a scimitar vein on the chest radiograph, six (54.55%) cardiac dextroposition, six (54.55%) pulmonary hypoplasia, five (45.45%) right pulmonary artery hypoplasia, and three (27.27%) had aortopulmonary collaterals. Four (36.36%) patients had horseshoe lungs, and four (36.36%) had bronchopulmonary sequestration. In the associations, two (18.18%) patients were found to have an atrial septal defect, three (27.27%) ventricular septal defect, and one (9%) had Tetralogy of Fallot. Pulmonary hypertension was demonstrated in two (18.18%) patients. Seven (63.64%) required surgical management to correct the scimitar vein, and two patients died due to unrelated complications. Scimitar syndrome presents diagnostic and treatment challenges, necessitating a multidisciplinary approach for timely care. Chest radiography and CT scans are primary diagnostic tools, with surgical intervention often warranted alongside other heart defects or significant hemodynamic repercussions. Medical management is effective for mild to moderate cases. Long-term patient outcomes remain uncertain due to study limitations, but improved life expectancy is anticipated with ongoing care.

Management of right ventricular outflow tract with percutaneous Melody valve implantation in pediatric patients: experience in a high complexity center in Colombia.

BACKGROUND: Congenital heart disease poses a therapeutic challenge, specifically pulmonary valve stenosis. This has been treated for many years with invasive procedures and bioprostheses, which over time, become dysfunctional due to the accumulation of fibrous tissue and calcification. OBJECTIVE: The aim of this study is to describe the use of endovascular management in the right ventricular outflow tract, as the beginning of an ongoing effot to improve pediatric outcomes in developing countries. METHODS: Seven pediatric patients with endovascular management of the right outflow tract are presented. Three of them underwent surgical valvuloplasty with persistent pulmonary stenosis. They decided to insert a percutaneous transcatheter pulmonary valve (PPVI) with a Melody valve using the valve-in-valve technique, with 100% stenosis and no complications associated with the procedure. RESULTS: Four patients with successful percutaneous valve implantation had different congenital heart diseases. In addition, the case of a patient in whom an intentional pulmonary valve fracture was performed, an innovative procedure in pediatric endovascular management in the country, is highlighted. CONCLUSIONS: The procedure was minimally invasive, safe, and effective. The IVPP technique could be a viable option in our country for managing failed primary valve implantations or even in native tracts.

ANTECEDENTES: Las cardiopatías congénitas plantean un desafío terapéutico, específicamente la estenosis de la válvula pulmonar. Esta ha sido tratada durante muchos años con procedimientos invasivos e inserción de bioprótesis, que con el tiempo se vuelven disfuncionales y pueden reestenosarse por acumulación de tejido fibroso y calcificación. Debido a las complicaciones generadas por la injuria quirúrgica, se han descrito medidas menos invasivas para el manejo de la estenosis residual e inicial por medios endovasculares en adultos y más recientemente en población pediátrica. OBJETIVO: El objetivo de este reporte es describir la misma en el manejo endovascular del tracto de salida del ventrículo derecho, como el inicio de un trabajo continuo para la mejoría de los resultados pediátricos en países en vía de desarrollo. MÉTODOS: Se presentan siete casos pediátricos de manejo endovascular del tracto de salida derecho; tres de ellos sometidos a valvuloplastia quirúrgica con persistencia de la estenosis pulmonar, por lo cual se decidió inserción percutánea de una válvula pulmonar (IVPP) transcatéter con válvula Melody utilizando la técnica valve-in-valve, con lo que se consiguió una resolución del 100% de la estenosis y no se presentó ningún tipo de complicación asociada al procedimiento. RESULTADOS: En cuatro pacientes se logró una implantación exitosa de la válvula por vía percutánea en diferentes cardiopatías congénitas, siendo uno de ellos en tracto nativo; además, destaca el caso de un paciente en quien se realizó fractura intencional de la válvula pulmonar, procedimiento innovador en el manejo endovascular pediátrico en Colombia. CONCLUSIONES: En estos pacientes el procedimiento resultó ser poco invasivo, seguro y efectivo. La técnica IVPP podría ser considerada una opción viable en Colombia (y en otros países en desarrollo) para el manejo de implantes valvulares primarios fallidos o incluso en tractos nativos.

Experience of percutaneous closure of small to large patent ductus arteriosus with Nit-Occlud® device in a tertiary referral hospital in Colombia.

Background: The decision to close patent ductus arteriosus should always be individualized and taken together with the child's family once the risks and benefits of both choices have been exposed. Objective: This study aims to report the experience and outcomes in patients undergoing endovascular closure of small to medium-size PDA with a Nit-Occlud® device in a tertiary referral hospital in Colombia. Methods: Longitudinal descriptive study, which included all patients under 18 years of age who underwent percutaneous ductal closure with Nit-Occlud® device between January 1, 2011, and February 1, 2023. Patients with associated complex congenital heart disease requiring surgical management, pregnant patients, and patients with incomplete data regarding studied variables were excluded from the study. Results: Eighty-seven patients were documented, with a mean age, weight, and height at closure of 51 months, 14 kg, and 95.83 cm, respectively. About 70% of the patients (n = 61) were female, 76% were under 6-years-old and only one patient was over 15. The average size of the ductus at the pulmonary end was 2 mm. Four of the total number of patients did not achieve PDA closure during the procedure. Of the remaining 83, complete immediate closure was achieved in 81 patients. A device exchange for a larger device was required during the same procedure in one of the cases. Two patients presented residual shunt of 0.5 mm during follow-up, and one required a new procedure for device closure 10 months later. Only one device presented repeatedly embolization to the aorta, requiring surgical removal. As a technical difficulty, one device presented repeated passage into the aorta, so it was decided to remove it before releasing it to avoid complications, and given the complex anatomy of the ductus, surgical closure was indicated. Among the complications, one patient presented a hematoma of the subcutaneous tissue in the right thigh, which improved with medical management, and no deaths related to the procedure were registered. Conclusions: Using the Nit-Occlud® device to close small to moderate-sized ductus remains a safe and effective strategy with successful closure rates at 1-year follow-up irrespective of age, weight, height, or whether it involves a small or medium-sized duct. Despite our limitations, results concerning adverse effects are comparable to those observed in multicentric studies conducted in other regions.

Antecdentes: La decisión de cerrar el conducto arterioso permeable (CAP) siempre debe ser individualizada y tomada en conjunto con la familia del niño una vez expuestos los riesgos y beneficios de ambas opciones. Objetivo: Este estudio tiene como objetivo informar la experiencia y los resultados en pacientes sometidos a cierre endovascular del CAP de tamaño pequeño a mediano con un dispositivo Nit-Occlud® en un hospital de tercer nivel de referencia en Colombia. Método: Estudio descriptivo longitudinal, que incluyó a todos los pacientes menores de 18 años a quienes se les realizó cierre ductal percutáneo con dispositivo Nit-Occlud® entre el 1 de enero de 2011 y el 1 de febrero de 2023. Se excluyeron: pacientes con cardiopatía congénita compleja asociada que requirieron manejo quirúrgico, pacientes embarazadas y pacientes con datos incompletos sobre las variables estudiadas. Resultados: Se documentaron 87 pacientes, con edad, peso y talla promedio al cierre de 51 meses, 14 kg y 95.83 cm, respectivamente. El 70% de los pacientes (n = 61) eran mujeres, el 76% tenían menos de seis años y solo un paciente tenía más de 15 años. El tamaño medio del conducto en el extremo pulmonar fue de 2 mm. Cuatro del total de pacientes no lograron el cierre del CAP durante el procedimiento. De los 83 restantes, se logró el cierre inmediato completo en 81 pacientes. En uno de los casos fue necesario cambiar el dispositivo por uno más grande durante el mismo procedimiento. Dos pacientes presentaron shunt residual de 0.5 mm durante el seguimiento y uno requirió un nuevo procedimiento para cierre del dispositivo diez meses después. Solo un dispositivo presentó embolización repetida en la aorta, requiriendo extracción quirúrgica. Como dificultad técnica, un dispositivo presentó paso repetido hacia la aorta, por lo que se decidió retirarlo antes de liberarlo para evitar complicaciones y dada la compleja anatomía del ductus se indicó cierre quirúrgico. Entre las complicaciones, un paciente presentó un hematoma del tejido subcutáneo en el muslo derecho, que mejoró con el manejo médico, y no se registraron muertes relacionadas con el procedimiento. Conclusiones: El uso del dispositivo Nit-Occlud® para cerrar conductos de tamaño pequeño a moderado sigue siendo una estrategia segura y eficaz con tasas de cierre exitoso al año de seguimiento, independientemente de la edad, el peso, la altura o si se trata de un conducto de tamaño pequeño o mediano. A pesar de nuestras limitaciones, los resultados sobre los efectos adversos son comparables a los observados en estudios multicéntricos realizados en otras regiones.

Diagnostic Reference Levels in Interventional Pediatric Cardiology: Two-Year Experience in a Tertiary Referral Hospital in Latin America.

The goal of the present study was to propose the first local diagnostic reference levels (DRLs) for interventional pediatric cardiology procedures in a large hospital in Colombia. The data collection period was from April 2020 to July 2022. The local DRLs were calculated as the 3rd quartile of patient-dose distributions for the kerma-area product (Pka) values. The sample of collected clinical procedures (255) was divided into diagnostic and therapeutic procedures and grouped into five weight and five age bands. The Pka differences found between diagnostic and therapeutic procedures were statistically significant in all weight and age bands, except for the 1-5-year age group. The local DRLs for weight bands were 3.82 Gy·cm2 (<5 kg), 7.39 Gy·cm2 (5-<15 kg), 19.72 Gy·cm2 (15-<30 kg), 28.99 Gy·cm2 (30-<50 kg), and 81.71 Gy·cm2 (50-<80 kg), respectively. For age bands, the DRLs were 3.97 Gy·cm2 (<1 y), 9.94 Gy·cm2 (1-<5 y), 20.82 Gy·cm2 (5-<10 y), 58.00 Gy·cm2 (10-<16 y), and 31.56 Gy·cm2 (<16 y), respectively. In conclusion, when comparing our results with other existing DRL values, we found that they are similar to other centers and thus there is scope to continue optimizing the radiation dose values. This will contribute to establishing national DRLs for Colombia in the near future.

CT-guided harpoon marking a ground-glass infiltrate: A case report.

Physicians are facing a growing challenge in characterizing suspicious pulmonary lesions through biopsy. Video thoracoscopic surgery is crucial for conducting surgical biopsies of these nodules. However, accurately identifying small pulmonary nodules, tiny, subsolid, and deep ones, remains a significant challenge due to the absence of digital palpation. One proposed technique for localization involves using a harpoon, initially designed for mammary nodules but also applied to pulmonary nodules. In cases involving solitary pulmonary nodules, histologic characterization is often necessary also accurate descriptions through computed tomography and the patient's clinical and epidemiologic context allow for a presumptive diagnosis. In this case, during an abdominal CT scan, a 49-year-old female patient was serendipitously found to have a ground-glass infiltrate in the anteromedial segment of the lower lobe of her left lung. Despite presenting with normal lung auscultation on physical examination, the increasing prevalence of subsolid lung nodules, combined with the contemporary era of minimally invasive surgery, prompted the medical team to employ CT-guided harpoon marking for precise lesion localization. Subsequent pathology analysis confirmed the presence of lepidic pattern adenocarcinoma. This case underscores the efficacy of the CT-guided harpoon marking approach, which significantly enhances surgical precision. Such precision is paramount in formulating individualized treatment strategies and follow-up plans for patients with similar clinical presentations.

Direct percutaneous embolization of superior rectal veins via an inferior mesenteric vein in a pediatric patient: A case report.

Portal hypertension is a frequent syndrome characterized by an increased portal pressure gradient. The relevance of portal hypertension derives from the frequency and severity of its complications. Rectal varicose is relatively common in portal hypertension patients with meager bleeding rates; However, rectal variceal bleeding is a complicated and sometimes life-threatening condition. The management of rectal variceal bleeding has yet to be adequately established. Endoscopy, surgery, or transjugular intrahepatic portosystemic shunt placement (TIPS) can be performed in patients with gastrointestinal bleeding secondary to portal hypertension due to different etiologies. We present a successful case of direct abdominal percutaneous embolization of multiple and tortuous superior rectal varicose via the inferior mesenteric vein in a 7-year-old female patient with refractory rectal variceal bleeding, not susceptible to endoscopic, surgical, or TIPS management.

Discrepancy rate and clinical impact of preliminary reports from radiology residents.

Background: Residents usually cover night and weekend shifts issuing the preliminary reading of radiological studies in university hospitals. This is essential to strengthening decision-making skills when facing complex cases independently. However, there should be a balance between patient safety and academic experience since some concern has been expressed about the accuracy of the interpretations generated by trainees. This work aims to evaluate and characterize the discrepancies in preliminary reports issued by radiology residents. Material and methods: Radiologists filled out a questionnaire to evaluate preliminary reports of trainees considering diagnosis, findings description, clinical approach changes, and critical findings. Analysis was performed considering modality, imaging type, body part, and resident academic year. A Chi-square test with a significance level α of 0.05 was used to make group comparisons. Results: A total of 9072 studies were reviewed. Major and minor overall discrepancy rates were 1.7% and 8.3%, respectively. Minor discrepancy rate, findings description, and critical findings identification improved with increasing academic year, both overall and by modality. Discrepancy rates were lower for CT than MR and neuroimaging than for body-imaging studies. The highest major and minor discrepancy rates as abdomen/pelvis CT and lumbar-spine MR, respectively. Two percent of reports presented discrepancies that could generate a medical approach change. Conclusion: Discrepancy rates are low and comparable with those reported in the literature. These rates tend to improve as the resident's academic year increases. Our results suggest that radiology residents' coverage of night shifts and weekends is a practice that benefits the educational process without negatively impacting patient safety.

Successful retrograde embolization through the arch of cavernous arteries of a bilateral post-traumatic arterio-cavernous fistula: case report.

Penile trauma is uncommon, with an incidence of 1/175,000 cases in emergency departments worldwide. Less frequent, there may be cases of penile fracture with the penis in a flaccid state and also develop vascular lesions such as rupture of the cavernous artery, pseudoaneurysms, and arterio-cavernous fistulas. We present a case of a 32-year-old male patient with the perineum and pelvis blunt trauma after a motorbike accident with a secondary bilateral arterio-cavernous fistula treated with retrograde embolization through the arch of cavernous arteries.

20 years of experience with the Fontan procedure: characteristics and clinical outcomes of children in a tertiary referral hospital.

INTRODUCTION: Without participating in a contractile chamber, the Fontan procedure seeks to create a separation of oxygenated and deoxygenated blood in patients with univentricular heart, reducing the risks of long-term hypoxemia and improving their survival. This study describes the clinical outcomes of children undergoing the Fontan procedure between 2000 and 2020 in a tertiary referral hospital care centre in southwestern Colombia. MATERIALS AND METHODS: A retrospective observational descriptive study. The 81 patients who underwent the Fontan procedure were included. Categorical variables were presented with percentages and continuous variables with measures of central tendency according to the distribution of the data evaluated through the Shapiro-Wilk test. Sociodemographic, clinical, surgical variables, complications, and mortality were described. RESULTS: Between 2000 and 2020, 81 patients underwent the Fontan procedure: 43 (53.1%) males and a median age of 5.3 years (interquartile range 4.3-6.6). The most common diagnosis was tricuspid atresia (49.4%). The median mean pulmonary arterial pressure was 12 mmHg (interquartile range 10-15), the Nakata index 272 mm2/m2 (interquartile range 204-327), and the McGoon index (interquartile range 1.86-2.3). Seventy-two (88.9%) patients underwent extracardiac Fontan and 44 (54.3%) patients underwent fenestration. The median hospitalisation days were 19 days. The main complication was coagulopathy (19.8%), mortality in the first month between 2000 and 2010 was 8.6%, and after 2010 was 1.2%. CONCLUSION: The Fontan procedure is a palliative surgery for children with complex heart disease. According to anatomical and physiological variables, the proper choice of patients determines the short- and long-term results.

Acute appendicitis after closed abdominal trauma: A case report.

We present the case of a 14-year-old female patient with no clinical history who was admitted due to an impact on the abdomen and pelvis with a soccer ball during a match and who developed acute post-traumatic appendicitis. Acute appendicitis is one of the most common causes of acute abdomen. The diagnosis is mainly clinical and based on definitive history; however, the images can be decisive for the diagnosis. The etiology of acute appendicitis is well-reported in the literature, with the traumatic mechanism being one of the etiologies described. Acute post-traumatic appendicitis is rare; a timely diagnosis requires a high index of suspicion, a careful history, and a physical examination. Imaging with ultrasound or computed tomography is recommended if there is a discrepancy between the medical history and physical examination.

Características y desenlaces clínicos de pacientes menores de 18 años tratados con oxigenación con membrana extracorpórea posterior a cirugía para la reparación o paliación de cardiopatías congénitas / Characteristics and clinical outcomes of patients under 18 years of age treated with extracorporeal membrane oxygenation after surgery for the repair or palliation of congenital heart disease

Resumen: Objetivo: determinar las características y desenlaces clínicos de pacientes menores de 18 años tratados con oxigenación con membrana extracorpórea (ECMO) posterior a cirugía para la reparación o paliación de cardiopatías congénitas en un centro de referencia del suroccidente colombiano entre 2015 y 2020. Método: estudio descriptivo longitudinal con recolección retrospectiva de la información. Resultados: entre enero de 2015 y diciembre de 2020, 77 pacientes requirieron ECMO posterior a cirugía cardiaca pediátrica, con una mediana de edad de < 1 mes, mediana de peso de 4 kg, tiempo de circulación extracorpórea de 202 minutos y tiempo de pinzamiento aórtico de 95 minutos. La cardiopatía congénita más ingresada a ECMO fue el síndrome de corazón izquierdo hipoplásico (19.4%) en su posquirúrgico de Norwood (18.1%). La mediana del tiempo de ECMO fue de 111 horas. La indicación más frecuente fue la disfunción ventricular (80.5%). El 80.5% presentó complicaciones y la reintervención por sangrado fue la más frecuente (46.7%). La sobrevida a la ECMO fue del 48% y la sobrevida general al momento del alta fue de 25.97%. La edad < 1 mes (p = 0.030), el ácido láctico preECMO ≥ 5 mmol/l (p = 0.014) y el tiempo de normalización del lactato ≥ 24 horas (0.021), se asociaron a un mayor riesgo de mortalidad al egreso hospitalario. Conclusiones: la ECMO proporciona un soporte adecuado posterior a la cirugía cardiaca pediátrica. La edad < 1 mes, el ácido láctico preECMO ≥ 5 mmol/L y el tiempo de normalización del lactato ≥ 24 horas fueron las variables que se asociaron con un mal resultado y mortalidad hospitalaria.

Abstract: Objective: to determine the characteristics and clinical outcomes of patients under 18 years of age treated with extracorporeal membrane oxygenation (ECMO) after surgery for the repair or palliation of congenital heart disease. Method: longitudinal descriptive study with retrospective data collection. Results: between January 2015 and December 2020, 77 patients required ECMO after pediatric cardiac surgery with a median age of < 1 month, median weight of 4 kg, ECC time 202 minutes (IQR 125-272 minutes), aortic cross-clamp time 95 minutes. 76.6% were supported with ECMO prior to their return to the ICU. The congenital heart disease most frequently admitted to ECMO was hypoplastic left heart syndrome (19.4%) in the Norwood postoperative period (18.1%). The median time of ECMO was 111 hours. The most frequent indication was ventricular dysfunction (80.5%). 80.5% presented complications and reoperation for bleeding was the most frequent of these (46.7%). ECMO survival was 48% and overall survival at discharge was 25.97%. Age < 1 month (p = 0.030), pre-ECMO lactic acid ≥ 5 mmol/l (p = 0.014), OR 0.260 and time of normalization of lactate ≥ 24 hours (0.021), OR 0.24 were associated with a higher risk of mortality at hospital discharge. Conclusions: ECMO provides adequate support after surgery for the repair or palliation of congenital heart disease. Age < 1-month, pre-ECMO lactic acid ≥ 5 mmol/l, and lactate normalization time ≥ 24 hours were the variables that were associated with poor outcome and hospital mortality.

Lead synovitis: The important role of radiology on diagnosis and follow-up: Case report.

We present the case report of a 67-year-old man with a history of a firearm injury on the left upper extremity 35 years ago. Lead synovitis and imaging features are reviewed, emphasizing radiology's crucial role in diagnosing and following this condition.

Glioblastoma in the optic chiasm: A case report.

Malignant optic gliomas are an uncommon pathology, with around 67 cases reported worldwide in the literature. We present the case of a 77-year-old-male with a two-month history of progressive vision loss, ultimately leading to bilateral blindness. The initial clinical suspicion was a non-inflammatory ischemic optic neuropathy. Stereotactic biopsy was performed on the optic chiasm, and the histopathological diagnosis was confirmed as Glioblastoma.

Endovascular therapy in cerebrovascular event due to internal carotid artery tandem injuries: a case report.

Internal carotid artery tadndem lesions are common and are associated with a worse prognosis. There is still no clarity on the endovascular therapy strategy that should be used in the setting of acute cerebrovascular events. We present the case of a patient with acute cerebral ischemia secondary to internal caroid artery tandem lesion, who underwent intracranial thrombectomy and early stenting of the extracranial occlusion, who in a 12-month follow-up did not present complications associated with the procedure, sequelae neurological, thromboembolic recurrence or hemorrhagic events.

Moebius sequence: radiological approximations to molecular disturbances: an overview.

Moebius sequence is one of the rarest congenital cranial nerve abnormalities. Approximately 300 cases have been recorded in medical literature usually from single case report. Frequently characterized by either partial or complete agenesis of the VI and VII cranial nerves, Moebius sequence is also accompanied by vascular abnormalities and other alterations such as an aberrant or hypoplastic posterior fossa. We present 3 patients with Moebius sequence and their clinical and radiological features along with a discussion of their diagnostic approximations. The 3 patients (1 male and 2 females) with ages ranging from 24 days to 7 years in both outpatient and inpatient settings in a high complexity health center. Clinical and radiologic diagnosis with magnetic resonance imaging showed to be consistent with Moebius sequence. Moebius sequence initial diagnosis is based exclusively on nonunified clinical criteria, and there is an apparent genetic pattern of inheritance. Diagnostic clues include the child's inability for proper facial expressions, affectations in eye convergence, or diminished functional hearing. A radiological approach through the use of specific MRI sequences is often warranted in order to not only approximate cranial nerve abnormalities but also accompanying structural malformations.