Giovanbattista Capozzi

Pulmonary Artery Growth After Palliation of Congenital Heart Disease With Duct-Dependent Pulmonary Circulation: Arterial Duct Stenting Versus Surgical Shunt

OBJECTIVES The aim of this study was to compare the pulmonary artery (PA) growth after arterial duct (AD) stenting versus modified Blalock-Taussig shunt (MBTS) in neonates with congenital heart disease with duct-dependent pulmonary circulation (CHD-DPC). BACKGROUND Arterial duct stenting is increasingly deemed a reliable alternative to surgical shunt in CHD-DPC. A stented duct might better adapt to the PA anatomy than a surgical conduit, thereby promoting a more uniform PA development. METHODS This study enrolled 27 patients with CHD-DPC submitted to AD stenting (n = 13, Group I) or MBTS (n = 14, Group II) at our institution. The PA growth was angiographically assessed with the Nakata and McGoon indexes as well as the individual PA z-scores. The right-to-left PA diameter ratio was considered as index of uniform growth. RESULTS After 10 +/- 5 months, both options had promoted a significant increase of the Nakata index (from 136 +/- 72 mm/m(2) to 294 +/- 99 mm/m(2), p < 0.0001, Group I; from 151 +/- 74 mm/m(2) to 295 +/- 177 mm/m(2), p < 0.003, Group II) and McGoon ratio (from 1.5 +/- 0.3 to 2.1 +/- 0.3, p < 0.0001, Group I; from 1.6 +/- 0.3 to 2.0 +/- 0.5, p < 0.01, Group II). However, the surgical shunt had caused a worsening of the left-to-right PA diameter ratio compared with AD stenting (0.9 +/- 0.1 Group I vs. 1.6 +/- 0.9 Group II, p < 0.01), due to preferential growth of the PA contralateral to the shunt. CONCLUSIONS Percutaneous AD stenting is as effective as MBTS in promoting a global PA growth in CHD-DPC. In addition, it ensures an even distribution of the pulmonary blood flow, thereby promoting a more balanced pulmonary vascular development than MBTS.

Early Increase of Carotid Intima-Media Thickness in Children with Parental History of Premature Myocardial Infarction

Background/objective: Increased carotid intima-media thickness (IMT) is an early manifestation of atherosclerosis. Our group has previously demonstrated that a parental history of premature myocardial infarction (PHPMI) is associated with an increase in carotid IMT in children-adolescents (mean age 13 years) and young adults (mean age 24 years). The aim of the present study was to evaluate if carotid structural changes are detectable in young children with PHPMI. Methods: 26 healthy children (9 males and 17 females; 5–12 years, mean age 9.1 (2.5) years) with PHPMI and 26 age-matched (plus or minus 1 year), sex-matched and body mass index-matched (BMI; plus or minus 20%) control subjects were enrolled in the study. They underwent high resolution B-mode ultrasonographic evaluation of common carotid artery IMT. Lipid profile, resting blood pressure and BMI were also evaluated. Results: Compared to controls, subjects with PHPMI had increased IMT of common carotid arteries (mean of combined sites: 0.444 (0.076) mm versus 0.382 (0.062) mm in controls, p = 0.001). Offspring of coronary patients showed an unfavourable lipid profile compared to controls; however, the association between a PHPMI and carotid IMT was independent of lipids, apolipoproteins and other traditional risk factors. Conclusions: Vascular structural changes are detectable in subjects with PHPMI at a young age and occur independently of several traditional cardiovascular risk factors.

Congenital heart disease in live-born children: incidence, distribution, and yearly changes in the Campania Region.

Objectives Congenital heart disease (CHD), the most common cardiac malformation in the fetal and neonatal period, represents a heterogeneous group of defects with little known cause. The aim of this study was to investigate the incidence rate (IR) of CHD without spontaneous resolution in the first year of life, the age at diagnosis, the most common type of CHD, and the IR changes in severe and nonsevere CHD during the study period. Methods From January 1997 to December 2002, 4559 live births with CHD (diagnosed until December 2004) were enrolled in the Campania Region. Number of live-born children by month was derived from national registries. Results About 70% of CHD patients were diagnosed within the first year of life. The overall mean regional IR of CHD was 11.1 (confidence interval 10.8–11.4) patients per 1000 live-born children. The overall mean IR of CHD was significantly different in the five provinces of the Campania Region, but the annual IR remained stable in each of them throughout the study period. The relative risk in live-born children and residents in the areas with an elevated IR of CHD was higher for nonsevere CHD, but of low significance for severe CHD. At least one-third of CHD patients had atrial septal defects. Conclusions We described the highest IR of CHD from one of the largest samples used up to now for this purpose (410 181 live-born children), but we think that this value could be higher (poor surveillance in some areas). Moreover, this study increases the awareness that CHD patients with a few symptoms are frequently underdiagnosed in areas with inadequate health services and that by an improved availability of pediatric echocardiographic assesments seem warranted. Eight years of surveillance and an increasing attention of both pediatricians and cardiologists to mild CHD in some provinces allowed us to demonstrate that, despite previous reports, the most common CHD in our region was atrial septal defect.

Patent ductus arteriosus: patho-physiology, hemodynamic effects and clinical complications

During fetal life, patent arterial duct diverts placental oxygenated blood from the pulmonary artery into the aorta by-passing lungs. After birth, decrease of prostacyclins and prostaglandins concentration usually causes arterial duct closure. This process may be delayed, or may even completely fail in preterm infants with arterial duct still remaining patent. If that happens, blood flow by-pass of the systemic circulation through the arterial duct results in pulmonary overflow and systemic hypoperfusion. When pulmonary flow is 50% higher than systemic flow, a hemodynamic “paradox” results, with an increase of left ventricular output without a subsequent increase of systemic output. Cardiac overload support neuro-humoral effects (activation of sympathetic nervous system and renin-angiotensin system) that finally promote heart failure. Moreover, increased pulmonary blood flow can cause vascular congestion and pulmonary edema. However, the most dangerous effect is cerebral under-perfusion due to diastolic reverse-flow and resulting in cerebral hypoxia. At last, blood flow decreases through the abdominal aorta, reducing perfusion of liver, gut and kidneys and may cause hepatic failure, renal insufficiency and necrotizing enterocolitis. Conclusions Large patent arterial duct may cause life-threatening multi-organ effects. In pre-term infant early diagnosis and timely effective treatment are cornerstones in the prevention of cerebral damage and long-term multi-organ failure.

Arterial duct stenting: Do we still need surgical shunt in congenital heart malformations with duct-dependent pulmonary circulation?

Background Despite current trends toward primary repair, surgical systemic-to-pulmonary shunt is still an invaluable palliative option in some patients with congenital heart defects and duct-dependent pulmonary circulation. However, arterial duct stabilization with a high-flexibility coronary stent could be an effective alternative in high-risk surgical candidates or whenever short-term pulmonary blood flow support is anticipated. Methods and results On the basis of ductal origin and morphology, the stenting procedure can be perfomed from an arterial or venous route. Following arterial duct angiographic imaging, the stabilizing stent is chosen to completely cover the entire ductal length and dilated slightly less than the proposed surgical shunt. Procedural failure depends mainly on ductal tortuosity and ranges around 10% of cases. Morbidity and mortality are 8–11% and less than 1%, respectively. Mid-term fate of the stented duct is spontaneous, slow and progressive closure within a few months. Compared with a Blalock–Taussig shunt, stented ducts result in similar but more uniform pulmonary artery growth over a mid-term follow-up. Conclusion Arterial duct stenting is a technically feasible, well tolerated and effective palliation in congenital heart disease with duct-dependent pulmonary circulation. It is advisable either in high-risk neonates or whenever a short-term pulmonary blood flow support is anticipated. The stented duct appears less durable than a conventional surgical shunt although it is highly effective in promoting a global and uniform pulmonary artery growth.

Parental history of premature myocardial infarction is a stronger predictor of increased carotid intima-media thickness than parental history of hypertension

An increased carotid intima-media thickness (IMT) is detectable in young subjects with parental history of premature myocardial infarction (PHPMI) or hypertension (PHH). In this study we evaluated if PHPMI and PHH exert a different influence on carotid IMT and if their conjunction produces additive effects. High-resolution B-mode ultrasonographic evaluation of common carotid artery IMT was acquired from 48 subjects without PHPMI and PHH (22 males, 26 females; mean age 22.1±4.9 years; controls), 24 age- (±1 year) and sex-matched subjects with PHH without PHPMI (PHH-positive/PHPMI-negative subjects), 24 age- and sex-matched subjects with PHPMI without PHH (PHH-negative/PHPMI-positive subjects) and 24 age- and sex-matched subjects with both PHPMI and PHH (PHH/PHPMI-positive subjects). Lipid profile, resting blood pressure, smoking behaviour and body mass index (BMI) were also assessed. Carotid IMT was smaller in controls (0.41±0.07mm) compared to PHH-positive/PHPMI-negative subjects (0.47±0.10, p=0.023), to PHH-negative/PHPMI-positive subjects (0.54±0.11, p<0.001) and to PHH/PHPMI-positive subjects (0.52±0.10mm, p<0.001). Carotid IMT was greater in PHH-negative/PHPMI-positive (p=0.006) and in PHH/PHPMI-positive (p=0.031) than in PHH-positive/PHPMI-negative subjects. No difference in carotid IMT was evident between PHH-negative/PHPMI-positive and PHH/PHPMI-positive subjects (p=0.549). In the comparison among subjects using multiple regression analysis, only PHPMI, age and BMI were independently associated with carotid IMT. In healthy young subjects with PHPMI and/or PHH, carotid IMT is increased. PHPMI is a stronger predictor of increased carotid IMT than PHH. PHH in conjunction with PHPMI does not add any further detrimental effect on carotid IMT.

Lipoprotein(a) concentration does not differ between sexes in healthy offspring of patients with premature myocardial infarction.

Aims Although a family history of coronary artery disease (CAD) is an established factor influencing lipoprotein(a) [Lp(a)] levels, the effect of sex on Lp(a) concentration remains unclear. A potential cause of the conflicting findings regarding the effect of sex on this novel CAD risk factor is the limited ability of the studies, to date, to adequately control for the potential confounding effect of CAD familial predisposition. Our purpose was to evaluate the influence of sex on Lp(a) concentration in healthy young individuals by controlling for family history of CAD. In order to achieve our goal, we compared Lp(a) levels in pairs of brothers and sisters with a positive parental history of premature myocardial infarction (PHPMI). Methods We measured Lp(a) concentration in 77 healthy brother–sister pairs with PHPMI (mean age: brothers: 18.4 ± 6.2 years and sisters: 18.1 ± 5.8 years). Total cholesterol, low-density lipoprotein (LDL)-cholesterol and high-density lipoprotein (HDL)-cholesterol, triglycerides, apolipoprotein (Apo) A-I and B were also measured. Results Lp(a) levels did not differ between siblings of different sex (male vs. female sex: 0.994 ± 1.29 vs. 0.860 ± 0.82 μmol/l, P = 0.940); moreover, the prevalence of elevated (>1.071 μmol/l) Lp(a) concentrations between sexes was the same (29.9%). As expected, compared to female sex, male sex showed higher total/HDL-cholesterol ratio (3.642 ± 0.99 vs. 3.329 ± 0.89, P = 0.017) and lower HDL-cholesterol (1.221 ± 0.24 vs. 1.343 ± 0.28 mmol/l, P = 0.001), Apo A-I (1.390 ± 0.20 vs. 1.474 ± 0.23 g/l, P = 0.003) concentrations and Apo A-I/Apo B ratio (1.632 ± 0.49 vs. 1.830 ± 0.66, P = 0.016). Conclusion Our results show that healthy young men with PHPMI have a similar Lp(a) levels but worse lipid profile than women.

Concomitant aortic and mitral regurgitations: a rare echocardiographic view.

A 62-year-old man was admitted for slight dyspnoea and progressive exercise intolerance. Significant cardiac findings were a proto-meso-diastolic murmur (2–3/6 Levine’s scale) at the second intercostal space on …