Sadettin Sezer

Do we need a femoral artery route for transvenous PDA closure in children with ADO-I?

Objective: The standard procedure in percutaneous closure of patent ductus arteriosus (PDA) with Amplatzer duct occluder-I (ADO-I) is transvenous closure guided by aortic access through femoral artery. The current study aims to compare the procedures for PDA closure with ADO-I: only transvenous access with the standard procedure. Methods: This study was designed retrospectively and 101 pediatric patients were included. PDA closure was done by only femoral venous access in 19 of them (group 1), arterial and venous access used in 92 patients (group 2) between 2004 to 2012 years. The position of the device and residual shunt in group1 was evaluated by the guidance of the aortogram obtained during the return phase of the pulmonary artery injection and guidance of transthoracic echocardiography. Shapiro-Wilk’s test, Mann-Whitney U, chi-squared tests were used for statistical comparison. Results: The procedure was successful in 18 (95%) patients in group 1 and 90 (98%) patients in group 2. Complications including the pulmonary artery embolization (n=1), protrusion to pulmonary artery (n=1), inguinal hematoma (n=3), bleeding (n=2) were only detected in group 2. In other words, while complications were observed in 7 (7.2%) patients in group 2, no minor/major complication was observed in group 1. Complete closure in group 1 was: in catheterization room 14 (77.8%), at 24th hour in 2 (11.1%), at first month in 2 (11.1%). Complete closure in group 2 was: 66 (73.4%) patients in the catheterization room, 21 (23.3%) at 24th hour, 3 (3.3%) at first month, complete closure occurred at the end of first month. Conclusion: In percutaneouse PDA closure via ADO-I, this technique can be a choice for patients whose femoral artery could not be accessed, or access is impossible/contraindicated. But for the reliability and validity of this method, randomized multicenter clinical studies are necessary.

Review of literature for the striking clinic picture seen in two infants of mothers with systemic lupus erythematosus

Fertility and maintanence of pregnancy is impaired in patients with SLE, which is an autoimmune disease commonly seen in women of childbearing age, due to disease-causing autoantibodies. The auto-antibodies transplacentally passing to the fetus may destroy the specific fetal tissues according to their types. These harmful effects may also continue in postnatal life. Here, we report two neonates born to mothers with SLE, and presented with clinically different pictures. The first case, who was born to a mother with asymptomatic SLE, had fetal arrhythmias in prenatal period, and developed complete AV block shortly after birth. Specific auto-antibodies of the mother and infant were positive. Permanent pacemaker was inserted into the infant. The second case was a completely healthy preterm infant who was born to a mother who had pre-eclampsia in pregnancy and diagnosed with SLE and class I lupus nephritis for 12 years. Severely affected infants may be born to asymptomatic mothers with SLE while the symptomatic mothers may have healthy babies. These contrasting clinical features of infants of mothers with SLE are associated with the type of disease-causing autoantibodies.

[Procedural success and short- and mid-term results of percutaneous closure of persistent arterial duct with the Amplatzer Duct Occluder II].

OBJECTIVES We evaluated the effectiveness and reliability of percutaneous closure of persistent arterial duct (PAD) with the Amplatzer Duct Occluder II (ADO II), together with short- and mid-term results. STUDY DESIGN The study included 16 patients (10 girls, 6 boys; median age 6 years; range 5 months to 12 years) who underwent percutaneous PAD closure with the ADO II device. The ductus diameter was less than 6 mm in all the cases. According to the Krichenko classification, 10 patients had type A, five patients had type E, and one patient had residual PAD. The patients were assessed by aortography and echocardiography. The mean follow-up was 13.9 months (range 2 to 23 months). RESULTS Closure of PAD was successfully performed via the arterial approach in all the patients. The median ductus waist diameter was 3 mm (range 2 to 5 mm), the median device waist diameter was 4 mm (range 3 to 6 mm), and the waist length was 4 or 6 mm. The mean fluoroscopy time and the mean procedure time were 10.6 min (range 4 to 39 min) and 30 min (range 18 to 80 min), respectively. Immediate aortography following the procedure showed shunt only through the device lumen. No residual shunt or increases in aortic and left pulmonary flow velocities were observed in echocardiographic examinations. No complications occurred during the procedure and follow-up. CONCLUSION In all the cases, the ADO II device was found effective and reliable for closure of PADs of less than 6 mm.

Importance of N-terminal pro-brain natriuretic peptide in monitoring acute rheumatic carditis

PURPOSE To detect the relationship of N-terminal pro-brain natriuretic peptide levels with clinical and laboratory findings by measuring them at diagnosis, during, and after treatment in children with acute rheumatic carditis. METHOD A total of 40 children including 20 acute rheumatic carditis patients aged between 5 and 16 years 20 healthy children as controls were included in the study. Blood was drawn from patients at diagnosis and in the first week, first month and third month after treatment in order to detect pro-brain natriuretic peptide, C-reactive protein levels and erythrocyte sedimentation rates. All patients underwent echocardiography. RESULTS The N-terminal pro-brain natriuretic peptide levels of children with acute rheumatic carditis were significantly higher than those of the control group at diagnosis and during treatment (p<0.05). Echocardiographic evaluation of acute rheumatic carditis patients revealed that the left atrium diameter continued to decrease during the study and that the mean left atrium diameters measured at diagnosis and in the first week were statistically higher than the mean left atrium diameters measured in the third month. There was significant correlation between left atrium diameters at diagnosis and in the first month and N-terminal pro-brain natriuretic peptide levels during the same periods in the patient group. CONCLUSION Previous studies have used N-terminal pro-brain natriuretic peptide levels as a marker of enlargement of the left atrium, whereas in this study we want to emphasise its role as a marker of inflammation. This increase was significantly correlated with enlargement in the left atrium. N-terminal pro-brain natriuretic peptide levels were found to be a valuable determinant in indicating cardiac inflammation and haemodynamics.

Atrial fibrillation as an uncommon presentation in a large pleomorphic xanthoastrocytoma.

Atrial fibrillation (AF) is a rare rhythm that presents in children. It is defined as a disorganized, rapid atrial activity, with atrial rates ranging from 350 to 600 bpm. Various cardiac diseases, including ischemic heart disease, valvular diseases, atrial septal defect closure, and cardiomyopathy, are associated with AF [1–3]. Other systemic diseases, such as pulmonary embolism, hyperthyroidism, and many infections and inflammatory diseases, have been related to AF [1–5]. Atrial fibrillation was reported to be associated with arachnoid cyst in a 79-year-old woman [5]; Kneissl et al. [6] reported AF after the start of radiochemotherapy for a glioblastoma multiforme located at the right temporal lobe in a 49-year-old patient. Despite of these case reports, we did not encounter such a presentation at childhood in the English medical literature. In order to draw attention to this interesting association, we aimed to report a child with pleomorphic xanthoastrocytoma (PXA) who presented with AF.

Transapical aortic balloon valvuloplasty in a 6-year-old child with unsuccessful retrograde approach

Severely stenotic aortic valves can be treated by percutaneous techniques. However, in rare conditions it could not be possible because of vascular access and valvular passage problems due to small and eccentric orifice. Hybrid approach to balloon aortic valvuloplasty may be considered an alternative to surgery. Here, we present a case of a patient with severe aortic stenosis who has had two failed attempts of percutaneous intervention.

Transcatheter antegrade perforation and covered stent implantation to subatretic coarctation.

Subatretic coarctation is a complex form of aortic coarctation (CoA) with complete luminal obliteration (1-3). Surgical treatment of CoA has being performed successfully since 1940s. Nowadays balloon angioplasty and stent implantation are popular because transcatheter techniques for treatment of CoA are effective, with low morbidity and mortality rates (4, 5). Although endovascular stent implantation has risks and limitations in infants, stents currently are used routinely to dilate and support both native and recoarctations of children over 25 kg (6). In this report, a child with discrete CoA who had diagnosed subatretic coarctation and successfully treated with wire perforation of luminal obstruction followed covered stent implantation is presented.

Is hypertension the fate of aortic coarctation patients treated with Cheatham Platinum (CP) stent

AIM The aim of this study is to address the presence of hypertension and risk for cardiovascular diseases in patients with Coarctation of the Aorta (CoA) who were treated with endovascular stent placement. METHODS Twenty patients (mean age: 14.2 ± 3.9 years) who were treated with stent and 20 age- and sex-matched controls were included to the study. Structure and functions of left ventricle were assessed by echocardiography. Carotid intima media (CIM) thickness was measured by using sonography as a marker for detecting cardiovascular risk. As indirect marker of arterial stiffness, pulse wave velocity, and augmentation index were recorded by ambulatory blood pressure monitorization/arteriography device. RESULTS By ambulatory blood pressure monitorization, 24 h and daytime systolic and mean arterial pressure values were found to be significantly higher in patient group. Based on percentile values, 15% and 5% of patients were pre-hypertensive and hypertensive, respectively. Pulse wave velocity and cardiac output values were found to be significantly higher than control group. CIM thickness was also found to be significantly higher in patient group when compared to controls. CONCLUSIONS It was shown that hypertension incidence as demonstrated by ambulatory blood pressure monitorization and risk for cardiovascular diseases as indicated by CIM thickness and Pulse wave velocity were higher than those in healthy population even after CoA is corrected.

Is it safe to close ASD with the guidance of transthoraxic echocardiography in pediatric population "ten years' experience of a single center".

OBJECTIVE Main purpose of this study is to emphasize the usage and safety of transthoracic echocardiography (TTE) in percutaneous atrial septal defect (ASD) closure in appropriate pediatric cases. BACKGROUND Nowadays, percutaneous closure is preferred as treatment modality for ASD in pediatric age group. METHODS Between the dates December 2003-August 2013; 340 patients whose ASD were closed included in this study. Physical examination, electrocardiogram, TTE were done before the procedure, at the 24th hour, 1st and 6th month after the procedure. After the 6th month, routine control was done annually. Transesophageal echocardiography (TEE) was performed in 184 cases with large, multifenestrated ASD and when TTE views were poor in quality. We selected the 201 patients whose ASD diameter between 10-20 mm and formed 2 homogeneous groups according to the type of echocardiography used (TEE or TTE) in order to compare the role of echocardiography. RESULTS The demographic features of patients of 2 groups were similar. There was not any statistically difference between ASD, balloon sizing diameters between the groups. No statistically significant difference in the success, complication, and residual shunt rates was found between the groups. Procedure, fluoroscopy time, and amount were significantly higher in TEE group. When hemodynamic variables except pulmonary blood flow to systemic blood flow (Qp/Qs; right-left atrium mean pressure, pulmonary vascular resistance, and peak-mean pulmonary arterial pressure) were compared, there was not statistically difference. CONCLUSION TEE is an invasive procedure and requires general anesthesia, therefore, it should not be done routinely in ASD but only in selected cases. If the size and the anatomy of ASD is appropriate, TTE should be preferred primarily in percutaneous ASD closure.

OP-168 CP STENT IMPLANTATION IN THE CHILDREN WITH COARCTATION OF THE AORTA: SHORT-INTERMEDIATE-LONG TERM RESULTS FROM TURKEY IN A SINGLE CENTRE

Introduction Coarctation of the aorta is present in 5-8% of all patients with congenital heart disease and is seen in 0.04% of all live births. Since last two decade, transcatheter interventions have increased and have been adopted as the popular therapeutic approach of choice for many patients. Our aim was to evaluate patients with coarctation of aorta, who were treated by percutaneous stent implantation. Material-method Patients with aortic coarctation (n=35, 26 male) who had been treated with 38 stents (12 bare, 26 covered) were evaluated. The demographics, procedural and follow-up data were recorded from hospital registers and compared among the patient specifications (e.g. weight, coarctation nature). Results Mean follow-up time was 34 ± 16 months. Five patients (14.3%) were <20 kg, seven patients (20%) were <25 kg and 16 patients (45.7%) were <30 kg (11-70). There was a statistically significant difference between the patients with native coarctation (n=17) and recurrent coarctation (n=18) in terms of pre-procedural blood pressures, systolic gradients, coarctation diameters and the ratio of coarctation site diameter to descending aorta (CoA/DAo). While all patients received antihypertensive drugs before the procedure, the drug was discontinued in 26 patients during follow-up (p< 0.001). The procedure was successful in all patients (Figure 1-2). Stent migration was observed in four patients (11.4%) (all of them with recurrent coarctation) and peripheral arterial injury was seen in three patients (8.5%). On average 21 (6-42) months after the procedure, six patients underwent cardiac catheterization. Only one patient had an invasive gradient >20 mmHg. Four of these patients underwent balloon dilatation because of their hypertension. At least two years following the procedure, multislice CT was performed in 20 patients (57.2%). The patients who were evaluated by MSCT revealed no pathology such as restenosis, intimal proliferation in the lumen of the stent, aneurysm formation, stent fracture and migration (Figure 3-4). There was no statistically significant difference between the five patients weighed <20 kg and the other 30 patients in terms of demographic-procedural characteristics, procedure success and complication rates and follow-up data (table1-2) The pre-procedural, post-procedural and follow-up demographics and procedural characteristics of all 35 patients (26 male) are summarized in table 1-2