Ta-Cheng Huang

Treatment of acute Kawasaki disease: aspirin's role in the febrile stage revisited.

Objective. To evaluate the effect of treatment without aspirin in the acute phase of Kawasaki disease (KD) and to determine whether it is necessary to expose children to high- or medium-dose aspirin. Methods. A total of 162 patients who fulfilled the established criteria of acute KD between 1993 and 2003 were included in this retrospective study. All patients were treated with high-dose intravenous immunoglobulin (IVIG; 2 g/kg) as a single infusion without concomitant aspirin treatment. Low-dose aspirin (3–5 mg/kg per day) was subsequently prescribed when fever subsided. Patients who had defervescence within 3 days after the completion of IVIG treatment were classified as the IVIG-responsive group, and those whose fever persisted for >3 days were classified as the IVIG-nonresponsive group. The 162 patients were divided further into 2 groups: those who were treated with IVIG before illness day 5, and those who were treated after illness day 5. We compared the response rate of IVIG therapy, duration of fever, and incidence of coronary artery abnormalities (CAAs) between these groups. Results. A total of 153 patients were classified into the IVIG-responsive group, and 128 (83.66%) of them had defervescence within 24 hours after completion of IVIG therapy. Nine (5.56%) patients were classified into the IVIG nonresponsive group, and all received additional IVIG (2 g/kg) without aspirin. Six (66.67%) had defervescence within 3 days after additional therapy. Patients in the IVIG-nonresponsive group had a significantly higher incidence of CAAs than those in the IVIG-responsive group (25% vs 2.92%). In the group that was treated before illness day 5 (n = 16), all patients had defervescence within 3 days after IVIG therapy and 13 (81.25%) had defervescence within 24 hours. In the group that was treated after illness day 5 (n = 146), 137 (93.84%) patients had defervescence within 3 days and 115 (78.77%) had defervescence within 24 hours. One (6.67%) patient in the group that was treated before illness day 5 got a new onset of CAAs, as did 5 (3.85%) in the group that was treated after illness day 5. There was no statistically significant difference in the response rate of IVIG therapy, duration of fever, and incidence of CAAs between these 2 groups. Conclusion. The results of our study indicate that the treatment without aspirin in acute stage of KD had no effect on the response rate of IVIG therapy, duration of fever, or incidence of CAAs when children were treated with high-dose (2 g/kg) IVIG as a single infusion, despite treatment before or after day 5 of illness. We conclude that it seems unnecessary to expose children to high- or medium-dose aspirin therapy in acute KD when the available data show no appreciable benefit in preventing the failure of IVIG therapy, formation of CAAs, or shortening the duration of fever.

Use of Inoue balloon dilatation method for treatment of Cor triatriatum stenosis in a child

An 8‐year‐old girl was referred for evaluation of a heart murmur and progressive dyspnea with exertion. Transthoracic echocardiogram revealed Cor triatriatum with severe stenosis at its orifice. The resting transmembrane CW Doppler velocity was 2.3 m/sec. Cardiac catheterization and hemodynamic assessment were performed and demonstrated a marked increase in pulmonary capillary wedge and pulmonary artery pressures. The stenosis was successfully dilated with an Inoue balloon using a transseptal technique. This is the first description of dilation of a Cor triatriatum using the Inoue technique. Only one previous case report of balloon dilatation for Cor triatriatum sinister has appeared in the English literature using a different technique (double balloon method). Cathet Cardiovasc Intervent 2002;57:252–256.

Closure of Large Patent Ductus Arteriosus in Infants

The purpose of this study was to evaluate the feasibility, clinical outcome, and resource utilization of transcatheter closure of large, symptomatic patent ductus arteriosus (PDA) in young infants, and compare the results with those of surgery. From January 2003 to December 2006, successful transcatheter implantation of the Amplatzer duct occluder was performed in 20 young infants (< or = 3 months of age) with large PDA who suffered from severe congestive heart failure despite medical treatment. The data was compared with a historical control of 18 young infants who underwent surgical ligation of PDA. Patient ages ranged from 18 to 89 days (mean 51.8) in the study group and 13 to 82 days (mean 39.9) in the control group. Patient weight ranged from 2.7 to 7.1 kg (mean 4.24) in study group and 2.5 to 5.7 kg (mean 3.79) in the control group. Between the 2 groups, there was no significant difference in the rate of complications. Patients who underwent transcatheter closure utilized significantly fewer resources (length of hospital stay and total cost) than those who underwent surgery. In conclusion, percutaneous device occlusion with Amplatzer duct occluder in small, symptomatic infants is feasible and more cost-effective compared with surgery. In experienced hands with careful preprocedural evaluation and delicate manipulation, the safety of transcatheter closure with Amplatzer ductus occluder in this age group can be assured and major complication avoided. Revision of the delivery sheath, making it kink-resistant, and PDA shape-tailored devices should further optimize the procedure.

Reappraisal of the Prostaglandin E1 Dose for Early Newborns with Patent Ductus Arteriosus-Dependent Pulmonary Circulation

OBJECTIVES The usual initial dose of prostaglandin E1 (PGE1) for ductal-dependent congenital heart disease (CHD) is 50-100 ng/kg/minute. The aim of this study was to review our experience of a low initial dose of PGE1 treatment in early newborns with congenital heart disease and patent ductus arteriosus (PDA)-dependent pulmonary flow. METHODS We reviewed the clinical data of 33 newborns with CHD and PDA-dependent pulmonary circulation who were admitted from January 2005 to December 2010. Clinical parameters were collected, including, PGE1 dosage, oxygenation condition, vital signs, and other related clinical parameters during admission. Echocardiography was employed to assess the status of the PDA as clinically indicated. RESULTS Thirty-three newborns, including 17 males and 16 females, with CHD and PDA-dependent pulmonary circulation were enrolled in the study. Their mean age was 2.9 ± 5.1 (within the range of 1-26) days with a median of 1.0 day. Among the 33 cases, 25 were diagnosed with pulmonary atresia and eight with critical pulmonary stenosis. Twenty-five of our patients were treated with the initial low-dosage regimen of 20.0 ± 7.4 ng/kg/minute in our neonatal intensive care unit. None of these 25 patients with had significant apnea necessitating intubation and none had hypotension, fever, convulsion or cortical hyperostosis. Three of the eight patients who were treated with high-dose PGE1 (39 ± 13.2 ng/kg/minute) before referral to our unit had apnea and intubation after PGE1 use. All patients had adequate PDA patency with a low maintenance dose of 10.5 ± 5.3 ng/kg/minute before operation under our protocol. CONCLUSION In our experience, adequate PDA flows in early newborns with CHD and PDA-dependent pulmonary circulation could be achieved at a much lower dose than recommended in the literature. The lower dose of PGE1 also causes much fewer complications, such as apnea, fever, and hypotension. For early newborns with CHD and PDA-dependent pulmonary circulation, treatment with a lower initial dose of PGE1 of 20 ng/kg/minute and a maintenance dose of 10 ng/kg/minute is recommended.

A noninvasive sizing method to choose fitted Amplatzer septal occluder by transthoracic echocardiography in patients with secundum atrial septal defects

To simplify the conventional procedure, we developed a technique for transcatheter closure of atrial septal defects (ASDs) under transthoracic echocardiographic (TTE) sizing without balloon sizing. At present, device closure of interatrial communication has become a well-established technique to adequately treat severe left-to-right shunt associated with ASDs. During the traditional procedure, fluoroscopy with the waist of a compliant balloon is used to determine the appropriate size of the closure device and defect sizing. Choice of adequate closure device using transthoracic echocardiography (TTE) has been hitherto unreported. Between December 2002 and August 2004, 40 patients (15 males, 25 females, mean age 11.7 ± 7.8 years) with secundum ASDs underwent transcatheter closure at our institution. In group 1, 30 patients had the procedure by balloon sizing and TTE sizing. In 10 patients (group 2), TTE sizing was used as the sole tool for selecting device size and the device size was chosen to be based on the Amplatzer septal occluder (ASO) size and TTE size ratio in group 1. The procedure was performed under continuous transesophageal echocardiographic monitoring with general anesthesia. A correlation was found between TTE and stretched balloon sizing diameter SBD (y = 1.2645x − 1.4465; R2 = 0.9861), and between TTE size and ASO size (y = 1.3412x − 1.2864; R2 = 0.9929) in group 1. In group 2, a statistical correlation between TTE and ASO (y = 1.3419x − 0.1172; R2 = 0.9934) was also found. Good linear regression between TTE size and ASO chosen size was noted in group 1 and group 2 (R2 = 0.99). In group 2, successful device implantation was accomplished in all patients whose device size was chosen to be based on the ASO and TTE ratio in group 1. Transthoracic echocardiographic sizing is a safe and ideal method to measure interatrial defect and choose the occluding device, respectively. With our experience, the sizing based on TTE is generally easier than measurement from the balloon sizing.

Late coil migration due to thrombolysis after successful implantation of a coil for persistent ductus arteriosus

Transcatheter coil occlusion of persistent ductus arteriosus (PDA) is now a widely accepted treatment for PDA. However, late complication might occur due to thrombolytic treatment during the interventional period. We discuss a case with late coil migration due to thrombolysis after successful implantation of a coil. It should be emphasized that early thrombus formation is important for successful closure of PDA shunt using coil. Cathet. Cardiovasc. Intervent. 50:334–336, 2000.

Recognition of functional pulmonary atresia by color Doppler echocardiography.

Vigorous crying aids right ventricular ejection into the pulmonary artery. This phenomenon can differentiate functional pulmonary atresia from anatomic pulmonary atresia.