Luca Rosti

Early and late complications associated with transcatheter occlusion of secundum atrial septal defect

OBJECTIVES The goal of this study was to report the early and late complications experienced in atrial septal defect (ASD) transcatheter closure. BACKGROUND Atrial septal defect transcatheter occlusion techniques have become an alternative to surgical procedures. A number of different devices are available for transcatheter ASD closure. The type and rate of complications are different for different devices. METHODS Between December 1996 and January 2001, 417 patients (mean age: 26.6 +/- 19 years) underwent transcatheter occlusion of secundum type ASD. Complications were categorized into major and minor. Two different devices were used: the CardioSEAL/STARFlex in 159 patients and the Amplatzer septal occluder in 258 patients. RESULTS Thirty-four patients experienced 36 complications during the hospitalization (8.6%, 95% confidence interval: 6.1% to 11.1%). Ten patients underwent elective surgical repair because of device malposition (three patients) or device embolization (seven patients). Twenty-four patients experienced 25 minor complications: unsatisfactory device position or embolization. Devices were retrieved using a gooseneck snare and/or a basket; 11 patients experienced arrhythmic problems. Other complications were: pericardial effusion, thrombus formation on the left atrial disc, right iliac vein dissection, groin hematoma, hemorrhage in the retropharynx and sizing balloon rupture. Two patients had late complications: peripheral embolization in the left leg one year after implantation of an Amplatzer device and sudden death 1.5 year later. CONCLUSIONS Our series of patients with ASD by transcatheter occlusion shows that the procedure is safe and effective in the vast majority of cases. To further reduce the complications rate, the criteria of device selection according to ASD morphology and some technical tips during implantation are discussed.

Role of Heart Rate Variability in the Early Diagnosis of Diabetic Autonomic Neuropathy in Children

Background: Diabetic autonomic neuropathy (DAN) is a major complication of diabetes. DAN has been shown to be closely related to glycemic control. To contribute significantly to the morbidity and mortality of the disease, and to be indicative of an increased risk of cardiovascular events. Tests asssing the function of the autonomic nervous system, such as the response of heart rate and blood pressure to maneuvers stimulating the autonomic nervous system, including deep breathing. Valsalva maneuver and standing, allowed to detect signs of DAN in adolescents; however, the sensitivity of such tests in revealing an early impairment of the autonomic nervous system proved low. Several studies found heart rate variability (HRV) to be useful in assessing the dysfunction of the autonomic nervous system in diabetic children and adolescents, but only few HRV parameters were evaluated in most of them. Objective: To study cardiac autonomic nervous system in diabetic children, and to investigate whether the duration of diabetes and the degree of metabolic control are determinants for the development of DAN in children. Patients and Methods: We analyzed HRV in 50 asymptomatic patients with insulin-dependent diabetes mellitus (IDDM) and 30 healthy children matched for age and sex. Results: Patiens with a history of diabetes > 8 years showed significant alterations of the autonomic nervous systemm (significant reduction of r-MSSD, pNN50, HF and increase in LF/HF). Conversely, only a reduction in pNN50 was found in patients with a disease duration < 8 years. Furthermore, we also observed significant HRV abnormalities in patients with an impaired metabolic control of diabetes. Compared to controls, patients with glycosylated hemoglobin blood levels (HbA1C) > 8% showed a significant reduction of r-MSSD, pHH50 and total power spectrum, whereas no HRV abnormalities were detected in patients with an HbA1C < 8%. Conclusions: HRV analysis can detect early subclinical alterations of the autonomic nervous system in asymptomatic patients with IDDM, which seem to consist mainly in a parasympathetic impairment. Autonomic dysfunction is associated both with the duration and an inadequate metabolic control of the disease.Hintergrund: Die diabetische Polyneuropathie (DAN) ist eine Hauptkomplikation des Diabetes mellitus. Die DAN zeigt eine enge Beziehung zur Kontrolle der Blutzuckerwerte und trägt signifikant zur Morbidität und Letalität der Erkrankung bei und weist auf eine erhöhte kardiovaskuläre Ereignisrate hin. Die DAN kann bei Erwachsenen mittels spezieller Teste geprüft werden, die die Herzfrequenzänderung und das Blutdruckverhalten untersuchen, wenn Provokationsverfahren zum Beispiel mit Valsalva-Manöver, tiefer Atmung und Stehversuch durchgeführt werden. Die Teste weisen aber eine geringe Sensitivität auf. Die Herzfrequenzvaviabilität (HRV) selbst ist aber ein gutes Verfahren, um eine autonome Dysregulation aufzudecken. Ziel: Prüfung des autonomen Nervensystems bei Kindern mit Diabetes mellitus in Abhängigkeit von der Dauer und Schwere der gestörten Glucosestoffwechselsituation. Patienten und Methoden: Bei 50 Patienten mit insulinpfichtigem Diabetes mellitus und 30 gesunden Kindern wurde die HRV geprüft. Ergebnisse: Patienten mit einer Diabetesdauer über 8 Jahre zeigten eine signifikante Störung des autonomen Nervensystems mit Reduktion der HRV. War die Dauer des Diabetes weniger als 8 Jahre, war nur der Parameter pNN 50 erniedrigt. Eine gestörte HRV wurde nur bei Patienten mit geströter metabolischer Situation gefunden. Bei Patienten mit einem HbA1C Wert > 8% fanden sich erniedrigte Werte für r-MSSD, pNN50 und das Gesamtpowerspektrum im Vergleich zu Kontrollpersonen. Patienten mit HbA1C-Werten unter 8% blieben demgegenüber unauffällig. Schlussfolgerung: Die HRV-Analyse bei insulinplfichtigen Kindern mit Diabetes mellitus kann genutzt werden, um im subklinischen Bereich eine Störung der autonomen Funktion des Nervensystems zu überprüfen. Im Wesentlichen liegt eine Parasymathikusstörung vor. Die autonome Dysregulation ist korreliert zur Dauer und zum metabolischen Status der Kinder.

The effectiveness of octreotide in the treatment of post-operative chylothorax

Abstract. Chylothorax may be spontaneous or a complication of thoracic surgery. Treatment of this potentially harmful condition is not well established and may comprise dietary interventions and surgery. Somatostatin seems effective in the management of chylothorax, although its mechanism of action is unclear. Conclusion: octreotide, a somatostatin analogue, may be effective in the treatment of post-operative chylothorax.

Mechanical valves in the pulmonary position: a reappraisal.

OBJECTIVES To evaluate midterm results of mechanical valves in pulmonary position in patients with pulmonary regurgitation and right ventricular dysfunction as an alternative to bioprostheses. PATIENTS Mechanical valves (six tilting disc valves and two bileaflet valves) were implanted in eight patients previously operated on for tetralogy of Fallot (n = 7) and truncus arteriosus (n = 1), with severe right ventricular dysfunction caused by massive pulmonary regurgitation. RESULTS All patients survived prosthesis implantation and are currently well. At follow-up (3 months to 9 years), they do not show signs of valve failure, and right ventricular function has dramatically improved in all but one, who still shows moderate ventricular hypokinesia. CONCLUSION After operative correction of congenital heart defects in selected patients who show severe dysfunction of the right ventricle caused by pulmonary regurgitation/stenosis, mechanical valves may represent an alternative to bioprosthetic valves. The selection of the valve type is still a matter of debate. However, according to literature data, complications seem to have occurred only in patients with bileaflet mechanical valves in the pulmonary position, whereas no thromboembolic episodes or valve failure is reported in subjects with tilting disc valves in the right ventricular outflow. Tilting disc valves might perform better in the right ventricular outflow than bileaflet valves.

A comparison between the early and mid-term results of surgical as opposed to percutaneous closure of defects in the oval fossa in children aged less than 6 years

OBJECTIVES To compare surgical as opposed to percutaneous interventional closure of isolated atrial septal defects in the oval fossa in terms of hospital stay, efficacy, and complications, and to study the respective role of the two techniques in current practice. METHODS Between January 1998 and April 2004, 126 out of 1210 patients treated at our institution for closure of an isolated defect in the oval fossa were aged less than 6 years. The mean age of these 126 patients at procedure was 4.2 plus or minus 1 year. The ratio of females to males was 74 to 52. RESULTS Of the patients, 62% were treated successfully using a percutaneous approach. The groups treated surgically or percutaneously did not differ for age, gender, or indications for treatment. No deaths occurred. The rates of total and major complications were higher in the group undergoing surgical closure, at 34% versus 9%, p less than 0.0001, and 10.5% versus 1%, p equal to 0.01, respectively. Embolisation of the device requiring subsequent surgery occurred in 1% of patients. The stay in hospital was shorter in those closed percutaneously, at 3.2 plus or minus 0.9 days versus 6.8 plus or minus 2.8 days, p equal to 0.0001. During a mean follow-up of 3.4 plus or minus 1.9 years, no major complications occurred in either group, and symptoms improved significantly in both groups. Additional sequels occurred in 2 patients who had major complications subsequent to surgical closure. CONCLUSIONS Even in young children, it is both feasible and safe to close defects in the oval fossa percutaneously. Compared to surgical closure, the transcatheter approach allows a shorter stay in hospital, and has a lower rate of complications. Early and mid-term follow-up has confirmed the safety and efficacy of both techniques.

Rapid reversal of dilated cardiomyopathy following removal of neuroblastoma

Reported is a child with dilated cardiomyopathy, in whom medical therapy resulted in a mild improvement of cardiac function. Metabolic studies suggested the presence of a catecholamine-secreting tumour; and an adrenal neuroblastoma was identified and surgically removed. Following surgery, there was progressive and complete normalization of cardiac function. Although very rare, neurogenic tumours may be involved in the development of a dilated cardiomyopathy in the infant and child.

Extended end-to-end anastomosis with modified reverse subclavian flap angioplasty.

We report a surgical treatment for neonatal aortic coarctatin associated with distal aortic arch hypoplasia. This technique offers the possibility for augmentation of the aortic arch without sacrificing the subclavian artery or using prosthetic patch material. The procedure was successfully performed in 5 patients.

Neonatal Jaundice: Should We Go Crazy?

jaundice could lead parents or clinicians to treat jaundice more aggressively. However, the Danish study also lacked any information on phototherapy. Thus, if the association is real, it could be a result of phototherapy, rather than the jaundice itself, in which case, frightening families about jaundice could lead to an increase in treatment, which would be particularly counterproductive.

Neonatal pulse oxymetry as a screening for congenital heart disease: single or double recordings?

The paper by Riede et al. demonstrates further the usefulness and effectiveness of pulse oxymetry screening (POS) in the detection of critical congenital heart defects (cCHDs) by measuring oxygen saturation (SpO2) at 1 foot. They detected 14 neonates with cCHDs but missed four with cCHD, which is approximately one fourth of the patients with critical defects [2]. Single-site SpO2 is recommended even by the AHA and the AAP, but we may not rule out that at least one of the four infants “missed” by the authors could be identified with the adoption of a two-site recording (right arm and 1 foot) [1]. Actually, some cCHDs may be missed by the single-site POS because SpO2 may be higher (i.e. close to normal) in the legs than in the right arm and because pulmonary artery SpO2 are higher than in the aortic arch—this may happen with d-transposition of the great arteries in the first few days of life in Taussig-Bing anomaly, in total anomalous pulmonary drainage into superior vena cava and in infants with truncus arteriosus with interrupted aortic arch. In all these cCHDs, the higher SpO2 in the legs depends on the ductal shunting of (more) oxygenated blood to the descending aorta than to the aortic arch [3]. It is of note that these cCHDs are among those which may benefit more from prompt diagnosis and treatment. Therefore, despite the risk of increasing the number of false positives, it has been suggested that two-site POS may increase sensibility of the screening up to 92%. Finally, whether aortic coarctation may escape POS screening depends probably on the “dynamic” behaviour of this CHD, whose signs and symptoms appear when the ductus arteriosus begins to close—this underscores the need for an outpatient evaluation of “all” the neonates within 2– 3 days after discharge home, with routine evaluation of peripheral pulses.

Cerebral infarction after Fontan procedure for tricuspid atresia

Cerebrovascular accidents are a rare but feared complication of open heart surgery. We report a child with tricuspid atresia who suffered cerebral infarction after a Fontan procedure and discuss possible risk factors.