Iyad Al-Ammouri

Kawasaki disease in Jordan: demographics, presentation, and outcome

Kawasaki disease is the leading cause of acquired coronary artery disease in young children. There is a lack of data on Kawasaki disease and its effect on coronary arteries in Jordan and other developing countries. We report clinical and demographic data of Kawasaki disease in Jordan from a single institution, with emphasis on cardiac involvement and short to intermediate follow-up. Review of the medical records of 34 patients with Kawasaki disease from 1997 to 2010 was done for clinical and demographic variables. Echocardiographic and angiographic images were reviewed for patients at presentation and follow-up. The median age at presentation was 19 months, ranging from 2 months to 8 years, with a male to female ratio of 3.9:1. In all, 12 patients (35%) had incomplete Kawasaki disease. There was a high incidence of coronary artery involvement (41%), where 20.5% had aneurysms and 20.5% had ectasia without aneurysm. Most coronary aneurysms were present at the time of diagnosis. The only independent variable for prediction of coronary involvement was age, with an odds ratio of 0.63 per year (95% confidence interval 0.41-0.95).

Clinical presentation, etiology, and outcome of stroke in children: A hospital-based study

AIM To describe clinical presentations, etiologies, and outcomes of stroke in Jordanian children. PATIENTS AND METHODS We retrospectively reviewed the medical records of children diagnosed with ischemic stroke who presented to our clinic from January 2001 to June 2014. Patients with onset of stroke in the neonatal period were excluded. RESULTS Twenty-four children (12 boys and 12 girls, with a male to female ratio of 1:1) were included in this study. The follow-up period ranged from 1 month to 9 years. Age at onset of the first stroke ranged from 1 month to 13 years. The most common initial clinical presentation was hemiparesis (58.3%). A known etiology was identified in 58.3% of patients. The most common etiologies were metabolic disorders, such as mitochondrial encephalopathy lactic acidosis and stroke (MELAS) and homocystinuria (25%), cardiac disorders (17%), and coagulopathy, such as a homozygous mutation in the MTHFR gene and a factor V Leiden mutation (17%). Recurrence of both clinical and silent strokes occurred in 46% of patients, residual motor weakness occurred in 58.3%, and residual epilepsy occurred in 29.2%. CONCLUSION Metabolic disorders, cardiac disorders, and coagulopathy are the causes of strokes in Jordanian children. Our results emphasized the importance of inherited disorders in Jordan.

Massive Intra-Atrial Thrombosis in an 11-Year-Old Child With Restrictive Cardiomyopathy

An 11-year-old girl with a previous diagnosis of idiopathic restrictive cardiomyopathy at the age or 8 years of age presented to our institution with severe congestive heart failure and a small, right-atrial thrombus (Fig. 1 and Video 1). The patient was treated with intravenous heparin, followed by warfarin and aspirin, and was discharged home with therapeutic prothrombin time and international normalized ratio (INR) of 3. Two months later, she presented to the emergency room with recurrent epistaxis and worsening symptoms of heart failure. A few hours after admission to the hospital, she developed sudden-onset diplopia and dizziness, followed by seizure and loss of consciousness. Echocardiography performed a few minutes before fatal cardiac arrest showed massive left-atrial thrombosis despite an overtherapeutic INR of 7, with loose thrombus protruding through the mitral valve and poor leftventricular function (Fig. 2 and Video 2).

Effects of experimental acute myocardial infarction on blood cell counts and plasma biochemical values in a nude rat model (Crl:NIH-Fox1RNU)

To determine the clinical pathology parameters in nude rats (Crl:NIH-Fox1RNU) following experimental induction of acute myocardial infarction (AMI), 50 male adult nude rats weighing 250–350 g were used. Complete blood count, total and differential leukocyte counts, plasma total protein, albumin, glucose, urea, creatinine, total bilirubin, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyl transpeptidase were determined before (time zero, T0), 1, and 5 days following experimental induction of AMI. Lactate dehydrogenase, creatinine kinase (CK), and creatinine kinase MB fraction (CK-MB) were determined at T0, 6, and 24 h following AMI. There were no significant changes in the hematological parameters at any sampling point. Among all plasma biochemical parameters studied, only CK and CK-MB were significantly elevated 6 h following induction of AMI. These data will aid scientists and researchers in the interpretation and better application of their results when using nude rats for AMI studies.

Is pre-discharge echocardiography indicated for asymptomatic neonates with a heart murmur? A retrospective analysis.

OBJECTIVE The purpose of this study was to determine whether a murmur detected on routine pre-discharge examination of asymptomatic newborn children in the first 48 hours of life warrants further investigation with echocardiography. METHODS We conducted a retrospective review of all echocardiography studies of neonates born at Jordan University Hospital between August, 2007 and June, 2014. Findings on physical examination as well as the indication of the echocardiographic studies were reviewed. We included asymptomatic neonates for whom echocardiographic studies were carried out due to the sole indication of a heart murmur on routine pre-discharge neonatal physical examination. RESULTS Of 309 asymptomatic newborns with murmurs on pre-discharge examination, echocardiography revealed 68 (22%) cases of CHD, with 18 (6%) designated as significant heart disease with anticipated intervention during infancy or childhood. The most common abnormality was ventricular septal defect occurring in 36 cases. Critical heart diseases detected included hypoplastic left heart syndrome in two and aortic valve stenosis in four newborns. CONCLUSIONS Although most asymptomatic neonates with heart murmurs have normal hearts, a small percentage may have significant heart disease. The decision to refer an asymptomatic newborn with a murmur for echocardiography before discharge from the hospital remains controversial and must be supported by other evidence such as murmur characteristics and local trends in parental compliance with follow-up well-baby visits.

Anomalous right coronary artery origin from the pulmonary trunk in an asymptomatic 4-year-old boy.

An anomalous origin of a coronary artery from the pulmonary trunk, usually involving the left coronary artery, is a well-known congenital coronary anomaly. Origin of the right coronary artery from the pulmonary trunk is much less common and can be isolated or associated with other congenital heart disease in up to 40% of patients [3]. Presenting symptoms may be related to coronary ischemia or due to the associated cardiac anomaly. The anomaly also may be discovered incidentally in asymptomatic patients [1–4]. A 4-year-old asymptomatic boy referred for a routine cardiac evaluation to assess a heart murmur was found to have a soft but continuous murmur and a normal electrocardiogram. The echocardiogram showed a dilated left coronary artery with abnormal diastolic flow into the main pulmonary artery (Fig. 1; online movie) and multiple abnormal flow patterns within the myocardium of the ventricular septum. The ventricular function was normal. The diagnosis of anomalous coronary artery from the pulmonary artery was confirmed by cardiac angiography (Fig. 2). The patient underwent surgical reimplantation of the right coronary artery to the aortic root without complications. Follow-up echocardiography showed a normal flow pattern in both coronary arteries.

Neurological and cardiac complications in a cohort of children with end-stage renal disease.

Adult patients with chronic kidney disease are at risk of major neurologic and cardiac complications. The purpose of this study is to review the neurological and cardiac complications in children with end-stage renal disease (ESRD). A retrospective review of medical records of children with ESRD at Jordan University Hospital was performed. All neurological and cardiac events were recorded and analyzed. Data of a total of 68 children with ESRD presenting between 2002 and 2013 were reviewed. Neurological complications occurred in 32.4%; seizures were the most common event. Uncontrolled hypertension was the leading cause of neurological events. Cardiac complications occurred in 39.7%, the most common being pericardial effusion. Mortality from neurological complications was 45%. Neurological and cardiac complications occurred in around a third of children with ESRD with a high mortality rate. More effective control of hypertension, anemia, and intensive and gentle dialysis are needed.

Severe coarctation of the aorta in a 900 g donor of twin-twin transfusion newborn with successful repeated transcatheter angioplasty: a case report.

We present a case of severe aortic coarctation in a donor of twin-twin transfusion syndrome. Patients underwent two angioplasty procedures at age 7 and 47 days, weighing 900 and 1500 g, respectively. Umbilical artery approach was used in the first procedure, and femoral artery approach was used in the second. Follow-up at the age of 13 months showed no recurrence of coarctation.

Late presentation of persistent left superior caval vein in a univentricular heart with successful transcutaneous occlusion using cera lifetech atrial septal occluder.

We present a case of persistent left superior caval vein in a univentricular heart presenting with progressive and disabling cyanosis in a 35-year-old man eighteen years after his Kawashima operation. The vein was successfully occluded using an atrial septal occluder with significant improvement of symptoms and oxygen saturation.

Circumferential stent fracture repaired using a covered stent in a 42-year-old man with coarctation of the aorta

We present a case of circumferential fracture of aortic coarctation stent with severe re-stentosis presenting 16 years after initial stent implantation with end-stage renal disease. The patient was treated with a covered stent using the stent-in-stent technique. The use of an ultra-high-pressure balloon was proved necessary to overcome the tight, non-compliant stenosis.