Evolution of paced QRS and QTc intervals in children with epicardial pacing leads

Aims : Permanent ventricular pacing in children is associated with ventricular dysfunction due to asynchronous activation. It is unclear whether paced QRS intervals increase disproportionately over time, which could potentially cause ventricular dysfunction. Methods : A total of 52 children, with bipolar steroideluting epicardial leads implanted at a median age of 5.6 years (0.0-17.4), was analyzed and followed up to 12.2 years (median 3.7). Patients were subdivided in two groups: right (RV, n = 21) and left (LV, n = 31) ventricular pacing. To correct for age, standard deviation scores (Z-scores) for paced QRS and QTc intervals were calculated from published standard-ECG norm-values. As a measure for individual paced QRS and QTc interval changes, a regression slope coefficient (inclinei) was calculated for each patient's course. Results : Mean Z-scores for paced QRS intervals at first and last follow-up were 4.7 ± 1.2 and 4.9 ± 0.9 for group RV, 4.4 ± 1.1 and 4.8 ± 1.1 for group LV. Inclinei of paced QRS (group RV: 0.038 [-0.27-0.12], group LV: 0.147 [-0.05-0.30]; p = 0.07) and QTc intervals (group RV: 0.026 [-0.08-0.06], group LV: 0.023 [-0.04-0.09]; p = 0.63) did not differ between both groups and indicated limited interval changes over time. Conclusion : Neither epicardial pacing of the right nor left ventricle caused disproportionate paced QRS or QTc interval increases over time. An age-related prolongation of the electrical activation unlikely causes ventricular dysfunctio

Comparison of surgical and interventional therapy of native and recurrent aortic coarctation regarding different age groups during childhood

Objective: The aim of the study was to analyze immediate results, rate of complications and re-interventions during medium-term outcome in pediatric patients with native or recurrent aortic coarctation. We focused on an age-related therapeutic approach comparing surgical and trans-catheter treatment. Methods: This is a retrospective, single-centre, clinical observational trial including 91 consecutive patients (age: 1 day-18 years) treated for native coarctation in 67 and recurrent aortic coarctation in 24 patients. Surgical treatment was performed in 56, trans-catheter treatment with balloon dilatation in 17, and by stent implantation in 18 patients. According to the age groups, we treated 48 children in group A (6 years). A total of 41 patients in group A were operated (85%), patients in group B received either surgical or trans-catheter treatment (50% vs 50%), and 16 patients in group C were treated by stent implantation (62%). Results: Immediate results were excellent with a significant release of pressure gradient in all three age groups (64.7% in group A, 69.1% in group B, and 63.3% in group C). Complication rate and re-intervention rate (surgical and interventional) were both comparable between the three age groups (complications: group A 8.3%, group B 6.3%, and group C 3.7%; re-interventions: group A 16.6%, group B 18.8%, and group C 18.5%). Midterm outcome after a median follow-up period of 17.5 months was satisfactory with a re-intervention-free survival after 17.5 months of 83.4%, 81.2%, and 81.5% in group A, group B, and group C, respectively. Conclusions: The current strategy of an age-related therapy for native and recurrent aortic coarctation in our institution is surgery in infants 6 years of age (group C) the trans-catheter treatment with stent implantation is an excellent alternative to surgery. Balloon dilatations showed limited results with an overall re-intervention rate of 53% and, therefore, should mainly be performed as a rescue procedure or in recurrent aortic coarctation in neonate

Left heart atrial and ventricular epicardial pacing through a left lateral thoracotomy in children: a safe approach with excellent functional and cosmetic results

Objective: Left heart atrial and ventricular epicardial pacing through a left lateral thoracotomy is an alternative approach for lead insertion in children, avoiding venous access complications and right ventricular stimulation, without compromising sporting or musical activities. We analyzed the survival and performance of left atrial and left ventricular epicardial pacing leads, and present mid-term follow-up data. Methods: Seventy-five bipolar steroid eluting pacing leads (Medtronic CapSure Epi 4968) were implanted in 41 children, aged 8.6+5.1 years. Pacing systems included 34 DDDR and 7 VVIR. Pacing leads were inserted through a muscle-sparing left lateral thoracotomy, and sutured to the left atrial appendage or atrium, and to the left ventricle. The generators were buried behind the abdominal muscles or between the thoracic muscle layers. Congenital heart disease with previous cardiac surgery was present in 25 children. Indications for pacing were post-operative heart block (n=14), sinus node disease (n=13), congenital heart block (n=9), and various (n=5). Threshold values and measured data were obtained at 6-month intervals. The mean follow-up was 3.8+2.9 years. Results: There was no mortality or major morbidity, with excellent functional and cosmetic results. Lead survival was 94 and 86% for atrial leads, and 97 and 86% for ventricular leads, at 1 and 5 years, respectively. There were five reoperations for lead fracture (n=2), insulation break (n=1), oversensing (n=1), and infection (n=1). Device reprogramming was required in three instances. In the absence of acute lead failure, mid-term follow-up shows very satisfactory and stable lead performance. Conclusions: Left heart atrial and ventricular epicardial pacing leads inserted through a left lateral thoracotomy demonstrate a high probability of survival, with favorable pacing characteristics, and optimal sensing thresholds at mid-term follow-up. Epicardial left heart pacing is reliable, and easy access can be achieved through a cosmetic and functional muscle-sparing left lateral thoracotom

Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects

Objective: We evaluated the mid-term results of the right axillary incision used for the repair of various congenital heart defects. Methods: All the patients who were operated with this incision between March 2001 and December 2007 were reviewed. There were 123 patients (median age 4.7 {0.4-19.4} years and median weight 16.6 {3.8-62} kg) undergoing atrial septal defect (ASD) closure (62), repair of partial anomalous pulmonary venous connection (PAPVC) (22), correction of partial atrioventricular septal defect (AVSD) (19), and restrictive perimembranous ventricular septal defect (VSD) (20). Additional procedures involved tricuspid valve plasty (10), mitral annuloplasty (3), reduction plasty of the aortic sinus (2), resuspension of the aortic valve cusp (2), sub aortic membrane resection (1), or reimplantation of Scimitar vein (1). The surgical technique involved peripheral (groin) and central (SVC ± aorta) cannulation for institution of cardiopulmonary bypass. Fibrillatory arrest was used for repair of ASDs and cardioplegic arrest for repairs involving the atrioventricular valves as well as VSDs. The median CPB and aortic clamp times were 72 (35-232) and 0 (0-126) min, respectively. Results: There was no need for conversion to another approach in any patient. Early morbidity included transient paresis of left upper arm (1), stenting of SVC after repair of a sinus venosus defect (1) and revision for bleeding (1). Follow-up echo showed no residual defect in 116 patients and minor residual defects in 7 patients: tiny ASD (2), tiny VSD (1) and mitral regurgitation (4). One patient developed stenosis in the right external iliac artery used for cannulation, necessitating surgical intervention. All the patients are in excellent condition after a median follow-up of 4.1 (0.4-7.1) years. The incision healed well and the thorax and the breast showed no deformity on follow-up. Conclusions: The right axillary incision provides a quality of repair for various congenital defects similar to that obtained by using standard surgical approaches. Because of its deceitful location, and the camouflaging effect of being hidden by the resting arm, it has superior cosmetic appeal compared to conventional incisions. The incision does not interfere with subsequent development of the thorax or the breast (in case of females

Do Predictors Exist for a Successful Withdrawal of Preoperative Prostaglandin E1 from Neonates with d-Transposition of the Great Arteries and Intact Ventricular Septum?

Prostaglandin E1 (PGE1) is given to neonates with d-transposition of the great arteries (d-TGA) to reduce cyanosis by reopening and maintaining the patency of the ductus arteriosus. To avoid side effects, this medication can be stopped for hemodynamically stable patients after balloon atrial septostomy (BAS). A consecutive series of neonates with d-TGA and an intact ventricular septum (IVS) presenting from 2000 through 2005 was analyzed retrospectively to search for side effects of PGE1 and to identify predictors for a safe preoperative withdrawal. The medication was stopped for hemodynamically stable patients with transcutaneous oxygen saturations higher than 80% after BAS and reinitiated for patients with an oxygen saturation lower than 65%. Patients successfully weaned were compared with those who had failed weaning in terms of atrial septal defect (ASD) size, ductus arteriosus size, and the transcutaneous oxygen saturation. Prostaglandin E1 was initiated for all 43 neonates with d-TGA. The median maintenance dose of PGE1 was 0.00625μg/kg/min (range, 0.00313-0.050μg/kg/min) for a median duration of 6days (range, 1-12days). For 16 patients, PGE1 was preoperatively withdrawn but then had to be reinitiated for 7 of the 16 patients. No predictors for a successful weaning of PGE1 were found based on ASD size, ductus arteriosus size, or oxygen saturation. The adverse effects of PGE1 were apnea in 10 patients and fever in 19 patients. Neither seizures nor necrotizing enterocolitis was documented. Prostaglandin E1 was successfully withdrawn for a minority of hemodynamically stable patients with d-TGA. No predictors for a successful weaning could be identified. Because apnea and fever are common side effects, withdrawal of PGE1 after BAS may improve patient safety and comfort. In this patient group, if PGE1 withdrawal was not well tolerated, it could be safely reinitiated. There were no serious side effects of PGE

Outcomes and reoperations after total correction of complete atrio-ventricular septal defect

Background: Surgical correction of complete atrio-ventricular septal defect (AVSD) achieves satisfactory results with low morbidity and mortality, but may require reoperation. Our recent operative results at mid-term were followed-up. Methods: From June 2000 to December 2007, 81 patients (Down syndrome; n=60), median age 4.0 months (range 0.7-118.6) and weight 4.7kg (range 2.2-33), underwent complete AVSD correction. Patch closure for the ventricular septal defect (VSD; n=69) and atrial septal defect (ASD; n=42) was performed with left atrio-ventricular valve (LAVV) cleft closure (n=76) and right atrio-ventricular valve (RAVV) repair (n=57). Mortality, morbidity, and indications for reoperation were retrospectively studied; the end point ‘time to reoperation' was analyzed using Kaplan-Meier curves. Follow-up was complete except in two patients and spanned a median of 28 months (range 0.4-6.1 years). Results: In-hospital mortality was 3.7% (n=3) and one late death occurred. Reoperation was required in 7/79 patients (8.9%) for LAVV insufficiency (n=4), for a residual ASD (n=1), for right atrio-ventricular valve insufficiency (n=1), and for subaortic stenosis (n=1). At last follow-up, no or only mild LAVV and RAVV insufficiency was present in 81.3% and 92.1% of patients, respectively, and 2/3 of patients were medication-free. Risk factors for reoperation were younger age (≪3 months; p=0.001) and lower weight (≪4kg; p=0.003), and a trend towards less and later reoperations in Down syndrome (p≪0.2). Conclusions: Surgical correction of AVSD can be achieved with low mortality and need for reoperation, regardless of Down syndrome or not. Immediate postoperative moderate or more residual atrio-ventricular valve insufficiency will eventually require a reoperation, and could be anticipated in patients younger than 3 months and weighing ≪4k

Haematological and infectious complications associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease

A complication is an event or occurrence that is associated with a disease or a healthcare intervention, is a departure from the desired course of events, and may cause, or be associated with, suboptimal outcome. A complication does not necessarily represent a breech in the standard of care that constitutes medical negligence or medical malpractice. An operative or procedural complication is any complication, regardless of cause, occurring (1) within 30 days after surgery or intervention in or out of the hospital, or (2) after 30 days during the same hospitalization subsequent to the operation or intervention. Operative and procedural complications include both intraoperative/intraprocedural complications and postoperative/postprocedural complications in this time interval. The MultiSocietal Database Committee for Pediatric and Congenital Heart Disease has set forth a comprehensive list of complications associated with the treatment of patients with congenital cardiac disease, related to cardiac, pulmonary, renal, haematological, infectious, neurological, gastrointestinal, and endocrinal systems, as well as those related to the management of anaesthesia and perfusion, and the transplantation of thoracic organs. The objective of this manuscript is to examine the definitions of operative morbidity as they relate specifically to the haematological system and to infectious complications. These specific definitions and terms will be used to track morbidity associated with surgical and transcatheter interventions and other forms of therapy in a common language across many separate databases. The MultiSocietal Database Committee for Pediatric and Congenital Heart Disease has prepared and defined a near-exhaustive list of haematological and infectious complications. Within each subgroup, complications are presented in alphabetical order. Clinicians caring for patients with congenital cardiac disease will be able to use this list for databases, quality improvement initiatives, reporting of complications, and comparing strategies for treatmen

Risk factors for reoperation after relief of congenital subaortic stenosis

Background: Congenital subaortic stenosis entails a lesion spectrum, ranging from an isolated obstructive membrane, to complex tunnel narrowing of the left outflow associated with other cardiac defects. We review our experience with this anomaly, and analyze risk factors leading to restenosis requiring reoperation. Methods: From 1994 to 2006, 58 children (median age 4.3 years, range 7 days-13.7 years) underwent primary relief of subaortic stenosis. Patients were divided into simple lesions (n=43) or complex stenosis (n=15) associated with other major cardiac defects. Age, pre- and postoperative gradient over the left outflow, associated aortic or mitral valve insufficiency, chromosomal anomalies, arteria lusoria, and operative technique (membrane resection (22) vs associated myectomy (34) vs Konno (2)) were analyzed as risk factors for reoperation (Kaplan-Meier, Cox regression). Results: There was no operative mortality. Median follow-up spanned 2.7 years (range 0.1-10), with one late death at 4 months. Reoperation was required for recurrent stenosis in 11 patients (19%) at 2.6 years (range 0.3-7.5) after initial surgery. Risk factors for reoperation included complex subaortic stenosis (p=0.003), younger age (p=0.012), postoperative residual gradient (p=0.019), and the presence of an arteria lusoria (p=0.014). For simple lesions, no variable achieved significance for stenosis recurrence. Conclusions: Surgical relief of congenital subaortic stenosis, even with complex defects, yields excellent results. Reoperation is not infrequent, and should be anticipated with younger age at operation, complex defects, residual postoperative gradient, and an arteria lusoria. Myectomy concomitant to membrane resection, even in simple lesions, does not provide enhanced freedom from reoperation, and should be tailored to anatomic finding

Remodelling of the right ventricle after early pulmonary valve replacement in children with repaired tetralogy of Fallot: assessment by cardiovascular magnetic resonance

Aims Correct timing of pulmonary valve replacement (PVR) is crucial for preventing complications of pulmonary regurgitation and right ventricular (RV) dilatation after repair of tetralogy of Fallot. We sought to assess the remodelling of the RV after early PVR in children, using cardiovascular magnetic resonance (CMR). Methods and results Twenty children with severe pulmonary regurgitation and RV dilatation and mean age 13.9±3 years underwent CMR evaluation 5.6±1.8 months before and 5.9±0.6 months after PVR. PVR was performed when the RV end-diastolic volume exceeded 150 mL/m2, as measured by CMR. The time interval between primary repair and PVR was 12±3 years. Post-operative CMR demonstrated a significant reduction of the RV end-diastolic volume from 189.8±33.4 to 108.7±25.8 mL/m2 (P<0.0001), of the RV end-systolic volume from 102.4±27.3 to 58.2±16.3 mL/m2 (P<0.0001), and of the RV mass from 48.7±12.3 to 35.8±7.7 g/m2 (P<0.0001). The RV ejection fraction did not change significantly. Conclusion Prompt RV remodelling, with reduction of RV volume and mass, is observed after performing PVR if the RV end-diastolic volume exceeds 150 mL/m2. Early PVR may prevent the detrimental complications of severe pulmonary regurgitatio