Echocardiographic Evaluation of Pulmonary Pressures and Right Ventricular Function after Pediatric Cardiac Surgery: A Simple Approach for the Intensivist.

Pulmonary hypertension (PH) is diagnosed using cardiac catheterization and is defined as an elevation of mean pulmonary artery pressure (PAP) greater than 25 mmHg. Although invasive hemodynamics remains the gold standard and is mandatory for disease confirmation, transthoracic echocardiography (TTE) is an extremely useful non-invasive and widely available tool that allows for screening and follow-up, in particular, in the acute setting. TTE may be a valuable alternative, allowing for direct measurement and/or indirect assessment of PAP. Because of the complex geometric shape and pattern of contraction of the right ventricle (RV), as well as the inherent complexity of cardiac repair, no single view or measurement can provide definite information on RV function and PAP and/or pulmonary vascular resistance. In addition, specific training and expertise may be necessary to obtain the views and measurements required. Some simple measurements may be of help when rapid evaluation is mandatory and potentially life saving: the assessment of tricuspid and/or pulmonary valve regurgitant jet and the use of the Bernoulli equation allow for measurement of PAP. Measurements such as the analysis of the pulmonary Doppler wave flow, the septal curvature, or the eccentricity index, assessing ventricular interdependence, are useful for indirect assessment. A four-chamber view of the RV gives information on its size, hypertrophy, function (fractional area change), and tricuspid annular plane systolic excursion as an evaluation of the longitudinal function. Based on these simple measurements, TTE can provide detection of PH, measurement or estimation of PAP, and assessment of cardiac function. TTE is also of importance in follow up of PH as well as providing an assessment of therapeutic strategies in the postoperative setting of cardiac surgery. However, PAP may be misleading as it is dependent on cardiac output and requires accurate measurements. In the presence of residual lesions, analyses of some Doppler measurements may be misleading and not reflect real PAP. Should the TTE evaluation reveal non-conclusive, invasive hemodynamics remains the gold standard

Review of inhaled iloprost for the control of pulmonary artery hypertension in children

In the pediatric population, pulmonary hypertension may present as an acute event in the setting of lung or cardiac pathology or as a chronic disease, mainly as idiopathic pulmonary hypertension or associated with congenital heart disease. Recently, new pharmacologic approaches have demonstrated significant efficacy in the management of adults with pulmonary arterial hypertension; these include intravenous epoprostenol, prostacyclin analogs, endothelin receptor antagonists and phosphodiesterase type 5 inhibitors. The same treatment strategies are currently used in children. There are only few reports of the use of inhaled iloprost in pediatrics, only one of which reported the use of chronic inhaled iloprost in a significant number of children. This report showed that 1) the acute pulmonary vasodilator response to inhaled iloprost is equivalent to that of inhaled nitric oxide; 2) acute inhalation of iloprost can induce bronchoconstriction 3) the addition of inhaled iloprost can reduce the need for intravenous prostanoid therapy in some patients; 4) most children tolerated the combination of inhaled iloprost and endothelin receptor antagonist or phosphodiesterase inhibitors; 5) Several patients had clinical deterioration during chronic inhaled iloprost therapy and required rescue therapy with intravenous prostanoids. In this review we will discuss the role of inhaled iloprost in acute and chronic pulmonary hypertension in children

Increase of Fungal Endocarditis in Children

Background:: Infective endocarditis (IE) is a rare and feared infection that mainly occurs in patients with underlying cardiac disease or altered function of the immune system. Recent epidemiological data on both sepsis and nosocomial infections indicate a rise in gram-negative bacterial and fungal infection, particularly in patients requiring critical care support. This study sought to characterize the change in the spectrum of IE encountered in a single pediatric tertiary care center during the last 18 years, to evaluate emergence of fungal IE and to identify contributing factors. Patients and Methods:: Review of all cases of IE diagnosed between January 1986 and August 2003 at a single university children's hospital. Patients were distributed between two equal time periods and compared according to the era of IE diagnosis. Results:: In 43 patients, 44 episodes of IE were identified with most cases occurring in children with congenital or acquired heart disease. The annual number of diagnosed cases fluctuated during the study (mean 2.4 cases/year). Blood or specimen cultures were positive in 34 cases (77%) with gram-positive organisms most frequently observed (n = 20, 44.4%). Fungal IE cases (n = 9, 20%) occurred preferentially during the second period (p < 0.03), and were more common in children with noncardiac diseases (p = 0.023). Factors associated with fungal IE were the use of broad-spectrum antibiotics (p < 0.001) and the presence of an infected central venous catheter (p = 0.01). Overall mortality did not differ between the two eras. Conclusion:: The incidence of fungal IE seems to have significantly increased in more recent years. Use of broadspectrum antibiotics for prolonged time or/and central venous catheters were identified as predisposing factors to fungal infective endocarditi