Transthoracic echocardiographically-guided interventional cardiac procedures in the dog

Objectives: Interventional cardiac procedures are traditionally performed using fluoroscopy, or, more recently, transesophageal echocardiography (TEE). Neither modality is widely available to practicing cardiologists worldwide. We examined whether balloon valvuloplasty of pulmonic stenosis (PS) and transarterial occlusion of patent ductus arteriosus (PDA) in dogs could be performed safely with transthoracic echocardiography (TTE). Animals, materials and methods: A prospective consecutive case series of 26 client-owned dogs with PS (n = 10) and PDA (n = 16). The cardiovascular procedures were performed using TTE. Each dog was positioned on a standard echocardiography table in right lateral recumbency (dogs with PS) or left lateral recumbency (dogs with PDA). Guide wires, balloon catheters, Amplatz® Canine Ductal Occluder (ACDO) delivery sheaths, and ACDO were imaged by standard echocardiographic views optimized to allow visualization of the defects and devices. Results: Procedures were performed successfully without major complications in 20 dogs. In 2 dogs (German Shepherds) with Type III PDA, ACDO placement was unsuccessful; 2 other German Shepherds were excluded from the procedure because their ductal diameters, measured echocardiographically, exceeded the limits of the maximal ACDO size. Two dogs weighing ≤ 3.5 kg had suboptimal echocardiographic visualization of the PDA and were considered too small for safe ACDO deployment. All intravascular devices at the level of the heart and great vessels appeared hyperechoic on TTE image and could be clearly monitored and guided in real-time. Conclusions: We have demonstrated that TTE monitoring can guide each step of pulmonic balloon valvuloplasty and PDA occlusion without fluoroscopy

Transesophageal echocardiography as the sole guidance for occlusion of patent ductus arteriosus using the Amplatz® Canine Ductal Occluder in dogs: a preliminary study.

Transesophageal echocardiography (TEE) has proven useful in evaluating patent ductus arteriosus (PDA) morphology thereby guiding appropriate device selection. Additionally, TEE, in combination with fluoroscopy, has been used to guide the transcathete 2012 ECVIM Abstracts 1515 coil embolization and for deployment of Amplatz Canine Ductal Occluder (ACDO) in dogs. Recently, we described the use of transthoracic echocardiography (TTE) guidance during transcatether PDA occlusion with ACDO without the use of fluoroscopy, but observed problems of deployment in patients with sub-optimal acoustic windows. However, TEE, can overcome issues of suboptimal TTE acoustic windows and provides higher image resolution of cardiac and vascular regions. Therefore, we hypothesized that TEE could be used to successfully visualize the vascular structures and interventional devices to safely perform PDA occlusion with ACDO without requiring fluoroscopy.We recruited 5 dogs with patent ductus arteriosus (PDA) for TEE-guided percutaneous ductal occlusion with an ACDO. Dogs were anesthetized, positioned in right lateral recumbency and the right femoral artery was accessed percutaneously (modified Seldinger technique). The TEE probe was advanced to a midesophageal position with minimal force to obtain a long axis 4-chamber view (transverse plane). The probe was then retroflexed and withdrawn to a cranial esophageal position until a cross section of the descending aorta was seen. To visualize PDA to the probe was slightly straightened and turned counterclockwise, and the ultrasonic beam was oriented between 60 and 120 degrees.In all dogs, the guide wire and a long introducer-sheath were guided from the aorta through the PDA into the main pulmonary artery by TEE monitoring. The ACDO was advanced through the introducer-sheath until the flat distal disk was visualized within the main pulmonary artery by TEE monitoring. The distal disk was positioned against the pulmonic ostium and the coupled proximal disk was deployed within the ductal ampulla while being monitored by TEE visualization.The guide wires, long introducer-sheath and ACDO appeared hyperechoic on TEE images and TEE guidance provided images of sufficient quality to clearly monitor the procedures in real-time. Real-time monitoring also allowed for immediate corrections to guide wire, catheter or device positioning. The procedures were successful and without complications in all patients.We have demonstrated that TEE monitoring, like TTE monitoring, can guide every step of transcatheter ACDO embolization procedures without requiring fluoroscopy, thereby avoiding radiation exposure, and provides an alternative to TTE-based guidance, especially when TTE visualization of the PDA is insufficient for safe and timely ACDO deployment

Transesophageal echocardiography as the sole guidance for occlusion of patent ductus arteriosus using the Amplatz® Canine Ductal Occluder in dogs: a preliminary study.

Transesophageal echocardiography (TEE) has proven useful in evaluating patent ductus arteriosus (PDA) morphology thereby guiding appropriate device selection. Additionally, TEE, in combination with fluoroscopy, has been used to guide the transcatheter coil embolization and for deployment of Amplatz Canine Ductal Occluder (ACDO) in dogs. Recently, we described the use of transthoracic echocardiography (TTE) guidance during transcatether PDA occlusion with ACDO without the use of fluoroscopy, but observed problems of deployment in patients with sub-optimal acoustic windows. However, TEE, can overcome issues of sub-optimal TTE acoustic windows and provides higher image resolution of cardiac and vascular regions. Therefore, we hypothesized that TEE could be used to successfully visualize the vascular structures and interventional devices to safely perform PDA occlusion with ACDO without requiring fluoroscopy.We recruited 5 dogs with patent ductus arteriosus (PDA) for TEE-guided percutaneous ductal occlusion with an ACDO. Dogs were anesthetized, positioned in right lateral recumbency and the right femoral artery was accessed percutaneously (modified Seldinger technique). The TEE probe was advanced to a midesophageal position with minimal force to obtain a long axis 4-chamber view (transverse plane). The probe was then retroflexed and withdrawn to a cranial esophageal position until a cross section of the descending aorta was seen. To visualize PDA to the probe was slightly straightened and turned counterclockwise, and the ultrasonic beam was oriented between 60 and 120 degrees.In all dogs, the guide wire and a long introducer-sheath were guided from the aorta through the PDA into the main pulmonary artery by TEE monitoring. The ACDO was advanced through the introducer-sheath until the flat distal disk was visualized within the main pulmonary artery by TEE monitoring. The distal disk was positioned against the pulmonic ostium and the coupled proximal disk was deployed within the ductal ampulla while being monitored by TEE visualization.The guide wires, long introducer-sheath and ACDO appeared hyperechoic on TEE images and TEE guidance provided images of sufficient quality to clearly monitor the procedures in real-time. Real-time monitoring also allowed for immediate corrections to guide wire, catheter or device positioning. The procedures were successful and without complications in all patients.We have demonstrated that TEE monitoring, like TTE monitoring, can guide every step of transcatheter ACDO embolization procedures without requiring fluoroscopy, thereby avoiding radiation exposure, and provides an alternative to TTE-based guidance, especially when TTE visualization of the PDA is insufficient for safe and timely ACDO deployment

Efficacy of adalimumab as second-line therapy in a pediatric cohort of crohn’s disease patients who failed infliximab therapy: The Italian society of pediatric gastroenterology, hepatology, and nutrition experience

BACKGROUND: Adalimumab (Ada) treatment is an available option for pediatric Crohn's disease (CD) and the published experience as rescue therapy is limited. OBJECTIVES: We investigated Ada efficacy in a retrospective, pediatric CD cohort who had failed previous infliximab treatment, with a minimum follow-up of 6 months. METHODS: In this multicenter study, data on demographics, clinical activity, growth, laboratory values (CRP) and adverse events were collected from CD patients during follow-up. Clinical remission (CR) and response were defined with Pediatric CD Activity Index (PCDAI) score ≤10 and a decrease in PCDAI score of ≥12.5 from baseline, respectively. RESULTS: A total of 44 patients were consecutively recruited (mean age 14.8 years): 34 of 44 (77%) had active disease (mean PCDAI score 24.5) at the time of Ada administration, with a mean disease duration of 3.4 (range 0.3-11.2) years. At 6, 12, and 18 months, out of the total of the enrolled population, CR rates were 55%, 78%, and 52%, respectively, with a significant decrease in PCDAI scores (P2 years was negatively correlated with final PCDAI score (P<0.01). Two serious adverse events were recorded: 1 meningitis and 1 medulloblastoma. CONCLUSION: Our data confirm Ada efficacy in pediatric patients as second-line biological therapy after infliximab failure. Longer-term prospective data are warranted to define general effectiveness and safety in pediatric CD patients

Efficacy of adalimumab as second-line therapy in a pediatric cohort of crohn’s disease patients who failed infliximab therapy: The Italian society of pediatric gastroenterology, hepatology, and nutrition experience

BACKGROUND: Adalimumab (Ada) treatment is an available option for pediatric Crohn's disease (CD) and the published experience as rescue therapy is limited. OBJECTIVES: We investigated Ada efficacy in a retrospective, pediatric CD cohort who had failed previous infliximab treatment, with a minimum follow-up of 6 months. METHODS: In this multicenter study, data on demographics, clinical activity, growth, laboratory values (CRP) and adverse events were collected from CD patients during follow-up. Clinical remission (CR) and response were defined with Pediatric CD Activity Index (PCDAI) score ≤10 and a decrease in PCDAI score of ≥12.5 from baseline, respectively. RESULTS: A total of 44 patients were consecutively recruited (mean age 14.8 years): 34 of 44 (77%) had active disease (mean PCDAI score 24.5) at the time of Ada administration, with a mean disease duration of 3.4 (range 0.3-11.2) years. At 6, 12, and 18 months, out of the total of the enrolled population, CR rates were 55%, 78%, and 52%, respectively, with a significant decrease in PCDAI scores (P2 years was negatively correlated with final PCDAI score (P<0.01). Two serious adverse events were recorded: 1 meningitis and 1 medulloblastoma. CONCLUSION: Our data confirm Ada efficacy in pediatric patients as second-line biological therapy after infliximab failure. Longer-term prospective data are warranted to define general effectiveness and safety in pediatric CD patients

Epidemiological trends of pediatric IBD in Italy: A 10-year analysis of the Italian society of pediatric gastroenterology, hepatology and nutrition registry

Introduction: The present study aimed at evaluating Italian epidemiological trends of pediatric inflammatory bowel diseases (IBD) over the period 2009-2018.Materials and methods: Data from 1969 patients enrolled in the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition Registry, by 49 pediatric IBD centers throughout the country, were analyzed, comparing three different time intervals (2009-2012, 2013-2015, 2016-2018).Results: The number of new IBD diagnoses ranged from 175 to 219 per year, evenly distributed over the examined period of time. From 2009 to 2018, the minimal incidence ranged from 1.59 to 2.04 /10 5 inhabitants aged &lt; 18 years, with an overall slight predominance of ulcerative colitis (UC) over Crohn's disease (CD) (ratio: 1.1). Mean diagnostic delay was 6.8 months for CD and 4.1 months for UC, with a significant reduction for CD when comparing the three-time intervals ( p = 0.008). The most frequent disease locations according to the Paris classification were ileocolonic for CD (41.3%) and pancolitis for UC (54.6%).Conclusions: The minimal incidence rate in Italy seems to have stabilized over the last two decades, even if it has increased when compared to previous reports. UC is still slightly more prevalent than CD in our country. Diagnostic delay significantly decreased for CD, reflecting an improved diagnostic capacity. (c) 2022 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved

Management of paediatric IBD after the peak of COVID-19 pandemic in Italy: A position paper on behalf of the SIGENP IBD working group

Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2, spreading in Italy during the first months of 2020, abruptly changed the way of practicing medicine in this country. As a consequence of the lockdown, the diagnostic and therapeutic management of paediatric chronic conditions, such as inflammatory bowel disease (IBD) has been affected. During the peak of COVID-19 pandemic, elective visits, endoscopies and infusions have been postponed, with potential clinical and psychological impact on disease course and a high likelihood of increasing waiting lists. While slowly moving back towards normality, clinicians need to recognize the best ways to care for patients with IBD, carefully avoiding risk factors for new potential epidemic outbreaks. In this uncertain scenario until the development and spread of COVID-19 vaccine, it is necessary to continue to operate with caution. Hereby we provide useful indications for a safer and gradual restarting of routine clinical activities after COVID-19 peak in Italy