Poonam P. Thankavel

Early echocardiographic prediction of ductal closure in neonates 30 weeks gestation

Objective:To determine the accuracy of the patent ductus arteriosus:left pulmonary artery ratio (PDA:LPA) on echocardiogram (ECHO) at 3-day postnatal in predicting spontaneous PDA closure in neonates ⩽30 weeks gestational age (GA).Study Design:ECHOs were performed at 72 h to characterize PDA size as closed-to-small (PDA:LPA <0.5) or moderate-to-large (PDA:LPA ⩾0.5) and at 10 days to determine spontaneous closure (defined as closed-to-small in the absence of medical and/or surgical treatment). Caretakers were blinded to results; treatment was based on standard care. Neonates were prospectively enrolled and stratified: <27 weeks (n=31) and 27 to 30 weeks (n=65).Result:Neonates <27 weeks with closed-to-small PDAs had 60% spontaneous closure vs 9% when moderate-to-large (positive predictive value (PPV) 60%, negative predictive value (NPV) 91%). Neonates 27 to 30 weeks had 95% spontaneous closure vs 27%, respectively (PPV 95%, NPV 73%). Inter-observer variability for the initial ECHO was 0.84.Conclusion:PDA size defined by PDA:LPA at 3 days postnatal in combination with GA predicts spontaneous PDA closure.

Elevated troponin levels in previously healthy children: value of diagnostic modalities and the importance of a drug screen

BACKGROUND Myocardial injury in previously healthy children is rare, with a wide range of aetiologies. It is increasingly being identified on the basis of elevated troponin levels during routine evaluation of cardiorespiratory symptoms. Establishing the aetiology remains challenging because of the lack of an accepted work-up algorithm. Our objective was to delineate the contribution of diagnostic modalities and troponin patterns towards the final diagnosis. METHODS A retrospective chart review of previously healthy patients admitted to the Pediatric Cardiology Service with myocardial injury was carried out. Data analysed included echocardiograms, electrocardiograms, cardiac catheterisations, magnetic resonance imaging, drug screen tests, troponin values, and final diagnosis. RESULTS A total of 32 patients were identified. The diagnoses were: myocarditis in 16 patients, vasospasm due to drug use in seven, myopericarditis in six, anomalous coronary artery origins in two, and Prinzmetals angina in one patient. The electrocardiograms were abnormal in 27 of the 32 patients (84%), echocardiograms in 18 of the 32 patients (56%), cardiac magnetic resonance imaging in two of the four patients (50%), urine drug screen in five of the 25 patients (20%), and cardiac catheterisations in two of the 15 patients (13%). CONCLUSIONS Myocarditis is the most common aetiology of myocardial injury in children. Clinical history remains the basic screening tool; drug screens help identify coronary vasospasms secondary to drug use (22% of our cohort). Patients with anomalous coronaries had exertional symptoms. Initial troponin levels and progression were not diagnostic or prognostic. Catheterisation is of limited value and did not change management. Magnetic resonance imaging with gadolinium enhancement is probably the most useful test when initial evaluation is not diagnostic.

Imaging the coronary artery: is it really normal? How to avoid common echocardiographic pitfalls.

Coronary artery anomalies in the absence of structural heart defects are rare with an estimated prevalence of 0.6% to 1.2% in the general population.1 Although the anomalous left coronary artery (LCA) from the right cusp is quite rare (0.03%–0.05% estimated prevalence2), it is frequently associated with sudden cardiac death, especially when intramural.3 A similar presentation has been described in 30% of patients with a right coronary artery from the left cusp.4 Given the unknown prevalence of this disease, the natural history of these lesions has not been truly defined. Transthoracic echocardiography remains the primary screening tool in young patients with exercise-induced cardiac symptoms.3 The accuracy of this modality in identifying the abnormal origin and course of coronaries has not been established, in part due to the unknown prevalence of the disease. The technical challenge of transthoracic echocardiography lies in obtaining reliable images of relatively small structures with translational movement during the cardiac cycle.3 Few prospective studies have sought to evaluate and overcome the limitations of transthoracic echocardiography. Transesophageal echocardiography, CT scan, and MRI have been recommended when a high index of suspicion is present.3 However, the rarity of congenital coronary abnormalities in young patients renders a low yield and cost-effectiveness of additional tests. To thoroughly evaluate the coronary arteries, it is important to understand the anomalous course of the vessel. Intraoperative assessment has often demonstrated …

Anomalous Left Main Coronary Artery Origin From the Right Sinus of Valsalva: A Novel Echocardiographic Screening Method

Anomalous origin of the left main coronary artery from the right sinus (ALMCA) is a rare entity associated with an increased risk for sudden cardiac death. Although transthoracic echocardiography often is the primary screening tool for the diagnosis, its accuracy remains undefined, resulting in the use of more expensive methods such as cardiac catheterization and magnetic resonance imaging when clinical suspicion exists. This report aims to describe a novel echocardiographic screening method for detecting ALMCA and to apply it retrospectively for patients with confirmed findings intraoperatively and/or on autopsy. All patients with a confirmed diagnosis of ALMCA who presented to our institution from 2004 to 2012 were included in the study. Eight patients had adequate images, including two patients with an initial diagnosis of normal coronary origins. A control group consisted of 35 patients with normal coronaries shown by echocardiogram. Five of these patients had normal coronary artery origins confirmed by magnetic resonance imaging (MRI). Echocardiographic images were reviewed, and the left main coronary was identified in the parasternal long-axis view between the aorta and pulmonary trunk. The angle of the left main coronary course was measured. In patients with ALMCA, the proximal course of the vessel was steeper as it coursed posteriorly. In contrast, the course was almost horizontal in patients with normal coronary origins. Based on these findings, a cutoff angle of 28° is proposed. In the parasternal long-axis view, ALMCA can be identified by its anomalous proximal course. This screening method is reliable and increases the accuracy of transthoracic echocardiograms.

Unruptured sinus of Valsalva aneurysm in a neonate with hypoplastic left heart syndrome: Echocardiographic diagnosis and features

An unruptured sinus of Valsalva aneurysm is usually asymptomatic, and a rare, often incidental echocardiographic diagnosis. Its presentation in the neonatal period is extremely rare. We describe this finding in a neonate with hypoplastic left heart syndrome, which has not been previously reported in the literature. This constellation of findings may have important clinical implications in regards to medical management and surgical options.

Relationship of Echocardiographic Z Scores Adjusted for Body Surface Area to Age, Sex, Race, and EthnicityCLINICAL PERSPECTIVE: The Pediatric Heart Network Normal Echocardiogram Database

Background— Published nomograms of pediatric echocardiographic measurements are limited by insufficient sample size to assess the effects of age, sex, race, and ethnicity. Variable methodologies have resulted in a wide range of Z scores for a single measurement. This multicenter study sought to determine Z scores for common measurements adjusted for body surface area (BSA) and stratified by age, sex, race, and ethnicity. Methods and Results— Data collected from healthy nonobese children ⩽18 years of age at 19 centers with a normal echocardiogram included age, sex, race, ethnicity, height, weight, echocardiographic images, and measurements performed at the Core Laboratory. Z score models involved indexed parameters (X/BSA&agr;) that were normally distributed without residual dependence on BSA. The models were tested for the effects of age, sex, race, and ethnicity. Raw measurements from models with and without these effects were compared, and <5% difference was considered clinically insignificant because interobserver variability for echocardiographic measurements are reported as ≥5% difference. Of the 3566 subjects, 90% had measurable images. Appropriate BSA transformations (BSA&agr;) were selected for each measurement. Multivariable regression revealed statistically significant effects by age, sex, race, and ethnicity for all outcomes, but all effects were clinically insignificant based on comparisons of models with and without the effects, resulting in Z scores independent of age, sex, race, and ethnicity for each measurement. Conclusions— Echocardiographic Z scores based on BSA were derived from a large, diverse, and healthy North American population. Age, sex, race, and ethnicity have small effects on the Z scores that are statistically significant but not clinically important.

A Neonate with Left Congenital Diaphragmatic Hernia and Transient Retrograde Flow in the Aortic Arch

Retrograde flow in the aortic arch identifies inadequate cardiac output in neonates with congenital heart disease. We present a left congenital diaphragmatic hernia (CDH) infant with retrograde flow in the arch that normalized after CDH repair. We hypothesize transient inadequacy of the left heart; prostaglandins might play a pivotal role.

Anomalous left pulmonary artery origin from internal carotid artery: prospective echocardiographic diagnosis of a previously unknown variant

We present a neonate with dextrocardia, tetralogy of Fallot, right arch, and aberrant left subclavian artery with left pulmonary artery origin from the left internal carotid artery, which is previously unreported.

Myocardial Contusion in an 8-Year-Old Boy: A Kick to the Heart

Myocardial contusion injury (MCI) may occur as a rare complication of blunt thoracic trauma, presenting with possible electrocardiogram (ECG) changes, rhythm disturbances, left ventricular systolic dysfunction, or troponin elevation. We present an 8-year-old boy with MCI after a kick to the chest by a horse and describe the use of diagnostic modalities and his clinical course. An 8-year-old previously healthy boy presented 2 hours after he was kicked in the chest by a horse. He was awake, alert, and oriented with normal vital signs, including a heart rate of 84 bpm. Physical examination was significant for superficial abrasions over his left chest and left chin. He sustained an incomplete distal ulnar fracture. Chest radiograph and a computed tomography scan without contrast of the chest and abdomen demonstrated extensive bilateral pulmonary contusions and a small right-sided pneumothorax. The initial ECG demonstrated bifascicular block (right bundle branch block and left anterior fascicular block; Figure 1), a well described, albeit rare, transient conduction abnormality that can be seen secondary to myocardial edema after significant MCI.1 Troponin I level at presentation was …

Double-outlet right atrium associated with hypoplastic right heart structures and aortic stenosis: echocardiographic features.

Case Report: A term, 3.1 kg newborn female with prenatal diagnosis of tricuspid and pulmonary atresia underwent transthoracic echocardiogram within the first few hours of life to evaluate intracardiac anatomy. Notably, a valve click was auscultated on physical examination. The electrocardiogram showed normal sinus rhythm and normal axes with voltages consistent with right atrial enlargement. The echocardiogram revealed an unrestrictive secundum atrial septal defect with right to left shunt, intact ventricular septum, and a hypoplastic and hypertrophied right ventricle. The ductus arteriosus was patent with left to right shunting into confluent branch pulmonary arteries. The tricuspid valve was noted to have 2 separate orifices, with the larger one being directed into the left ventricle (Fig. 1, movie clips