Patrick A. Flynn

Longitudinal Changes of Brain-Type Natriuretic Peptide in Preterm Neonates

OBJECTIVE. To determine age-related concentrations of brain-type natriuretic peptide in preterm infants using bedside Triage brain-type natriuretic peptide test and correlate it to the presence or absence of the patent ductus arteriosus and ventilatory support. METHODS. Serum brain-type natriuretic peptide levels were measured in infants who were born at <32 weeks’ gestation from birth to 2 months of age. Serial echocardiograms were performed, until closure of the patent ductus arteriosus, or until discharge. Brain-type natriuretic peptide levels were correlated to the day of life, gestational age, presence or absence of the patent ductus arteriosus, and the degree of ventilatory support. Nineteen preterm infants (gestational age: 24–31 weeks; birth weight: 645–1670 g) were enrolled prospectively during the first 2 weeks of life. Serum brain-type natriuretic peptide levels (pg/mL) were determined in 177 blood samples, and 87 paired echocardiograms were performed. RESULTS. Significant negative correlation was found between brain-type natriuretic peptide levels and the day of life and remained significant when the patients were stratified by gestational age (≤28 weeks and >28 weeks). Higher brain-type natriuretic peptide levels correlated with increasing grade of the patent ductus arteriosus. Significant differences in brain-type natriuretic peptide levels were seen with increasing ventilatory support. Comparisons between the size of patent ductus arteriosus and the degree of ventilatory support to brain-type natriuretic peptide levels revealed that the size of the patent ductus arteriosus was the major determinant of both brain-type natriuretic peptide levels and the degree of ventilatory support. CONCLUSIONS. Similar to term infants, brain-type natriuretic peptide levels of preterm infants are related to the chronological age and decline during the first month of life. Rapid bedside Triage brain-type natriuretic peptide is a potentially valuable and practical assay in determining the hemodynamic changes in preterm infants.

Atherosclerosis in Survivors of Kawasaki Disease

OBJECTIVES To test the hypothesis that long-term survivors of low-risk Kawasaki disease (KD) have ongoing vascular inflammation and dysfunction and a higher risk of accelerated atherosclerosis than healthy control subjects. STUDY DESIGN Twenty-eight patients with KD (7-20 years after acute illness) and 27 age-matched healthy control subjects were examined for medical and dietary history, serum markers of atherosclerotic risk and inflammation, carotid intimal-medial thickness (CIMT) with vascular ultrasound scanning and arterial stiffness with applanation tonometry. RESULTS Patients and control subjects were similar in age, sex, body mass index, waist-to-hip ratio, blood pressure, cigarette smoking, family history, diet, high-density lipoprotein cholesterol level, lipoprotein (a) level, homocysteine level, glucose level, insulin level, CIMT, arterial stiffness, C-reactive protein level, and inflammatory cytokine level. Levels of total cholesterol and apolipoprotein B were significantly higher in patients with KD than in control subjects. CONCLUSIONS There was no evidence of increased atherosclerosis. Small but significant differences in cholesterol and apolipoprotein B levels could suggest increased future risk for atherosclerosis and warrant further study.

Effectiveness of prostaglandin E1 in relieving obstruction in coarctation of the aorta without opening the ductus arteriosus.

The two main theories regarding the pathogenesis of coarctation of the aorta are the Skodaic hypothesis of ductal tissue constricting the aorta at the level of the insertion of the ductus arteriosus and the flow theory of decreased ascending aortic blood flow in the fetus, which results in associated isthmic narrowing and a localized shelf. To document that ectopic ductal tissue constriction can cause coarctation of the aorta in the absence of a patent ductus arteriosus, we report three cases of infants presenting with critical coarctation who responded to prostaglandin E1 infusion without opening the ductus arteriosus.

Cardiac Issues in the Pediatric Emergency Room

A great variety of problems referable to the cardiovascular system can prompt a visit to the pediatric emergency room. From the initial presentation of congenital heart disease, to the subsequent life-long management of these patients, to miscellaneous problems like Kawasaki disease and chest pain, the front-line pediatrician must be skilled in the recognition and early management of myriad complaints. This article focuses on information that can assist the emergency pediatrician in the evaluation and treatment of the cardiac patient from arrival in the emergency room until transfer of care to the pediatric cardiologist or inpatient staff.

Continuous intravenous diltiazem infusion for short-term ventricular rate control in children

Intravenous diltiazem was administered to 10 pediatric patients with primary atrial tachyarrhythmias with rapid ventricular response. Rapid, consistent, and safe temporary ventricular rate control was obtained in all patients given this medication.

Cardiac troponin I after cardiopulmonary bypass in infants in comparison with older children.

OBJECTIVE At the present time, there is a trend towards performing open heart surgery at a younger age. Myocardium of infants has been thought to be more vulnerable to cardiopulmonary bypass in comparison with adults. For this study, we evaluated the degree of myocardial injury by measurement of cardiac troponin levels in infants in comparison with older children for similar surgeries. METHODS Serum was collected before bypass, after bypass, and daily after surgery and serum cardiac troponin I level (micrograms per litre). The demographic data, cardiac diagnoses, types of surgery performed, and peri-operative parameters were collected. RESULTS Of the 21 children enrolled consecutively, five were infants. Among the 21 patients, four patients had post-operative peak troponin values greater than 100 (three were infants) and all four patients survived and had normal left ventricular systolic function upon discharge echocardiogram. The five infants had peak troponin levels of 222.3, 202, 129, 26.7, and 82.3. The post-operative peak troponin levels were significantly higher in infants (mean 132.5 with a standard deviation of 81.6) than in the older children (mean 40.3 with a standard deviation of 33.4), although there was no significant difference in bypass time, bypass temperature, cross-clamp time, or the length of stay in the intensive care unit between the two age groups. CONCLUSIONS Higher troponin release is seen in infants in comparison with older children after bypass for similar surgeries. A troponin level greater than 100 after bypass does not necessarily predict death or a severe cardiovascular event in the very young.

Aortic stenosis in hypoplastic right heart syndrome, associated with interstitial deletion of chromosome 2

This report describes a rare case of moderate to severe valvular aortic stenosis in the setting of severe tricuspid stenosis, pulmonary atresia with intact interventricular septum and right ventricular dependent coronary circulation. We discuss the clinical, hemodynamic, echocardiographic and angiocardiographic findings on this rare case and comment on accompanied malformations, with its possible association observed to the interstitial deletion of band q22 or q24 of the long arm of chromosome 2.

The findings of preoperative cardiac screening studies in adolescent idiopathic scoliosis.

Introduction: We sought to evaluate findings of screening cardiac studies in adolescent idiopathic scoliosis (AIS) patients by reviewing the echocardiograms and electrocardiograms (EKGs) performed at their preoperative evaluation for spinal fusion. Methods: Retrospective chart review of all surgical AIS patients from 2000 to 2007 was completed (n=212). Patients with neuromuscular scoliosis, known connective tissue disease, or known/suspected cardiac disease were excluded. In presurgical screening, 12 lead EKG, 2dimensional-Doppler, and M-mode echocardiograms were analyzed. Results: A total of 154 (73%) female and 58 (27%) male patients (aged 12 to 18 y, avg: 14.8 y) were analyzed. EKG findings, 180/212 (85%), were within normal limits. Twenty-eight of 212 (13%) patients were found to have normal variant readings. Four of 212 (2%) patients met criteria for left ventricular hypertrophy on EKG, but were subsequently found to have normal echocardiograms. Significant echocardiogram findings revealed 2 (0.94%) subjects with atrial septal defects (ASDs) (that delayed surgery) and 7 (3.3%) subjects with aortic root/valve abnormalities. Conclusions: In our cohort of preoperative AIS patients, cardiac abnormalities ranged from mild to severe, and in 2 cases, affected the surgical timing. Novel findings of aortic abnormalities were identified in 3.3% of patients. In a study which examined the prevalence of heart disease in randomly selected healthy adolescents with previously unknown cardiac disease (Steinberger), there was a rate of 3.6% (13/357) of cardiac anomalies. Of note, only 0.6% had aortic root/valve findings. The results of our retrospective review indicate that EKG does not provide significant information compared with echocardiogram as part of the preoperative evaluation of asymptomatic and otherwise healthy patients with AIS who are undergoing spinal deformity surgery. However, use of the echocardiogram may be appropriate for the diagnosis of previously unknown cardiac abnormalities in this population, as aortic root/valve abnormalities seem to be unique findings in these patients. Level of Evidence: Level IV, Retrospective, descriptive case series.

The Malignant Course of Acute Rheumatic Fever in the Modern Era: Implications for Early Surgical Intervention in Cases of Bivalvular Insufficiency With Impaired Ventricular Function

In recent years, the incidence of acute rheumatic fever (ARF) has drastically decreased in the United States while remaining common in developing nations. However, immigration to the United States from developing nations has resulted in the continued prevalence of ARF. Patients with ARF face the potential development of significant valvular insufficiency and rheumatic carditis, which are associated with significant morbidity and mortality. Potentially adverse outcomes may be avoided with advanced interventions such as aortic and/or mitral valve replacement or repair, the use of inotropic agents, and ventricular assist devices for mechanical circulatory support. This report describes a series of three ARF carditis cases. This series serves not only to emphasize proper ARF prevention, but also to demonstrate the need for timely surgical intervention once medical therapy has failed.

Fetal diagnosis of atrioventricular septal defect with dextrocardia in trisomy 18

Abstract On prenatal ultrasound atrioventricular septal defect is often diagnosed in infants with Down syndrome based on an abnormal four-chamber view of the heart. A unique case of atrioventricular septal defect with dextroposition of the heart in an infant with trisomy 18 is presented.