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Palladium(II) hexafluoroacetylacetonate (Pd(Hfacac)2) is known to form adducts of bases, such as lutidine (2,6-dimethylpyridine). When treated with approximately 3 equiv of lutidine, Pd(Hfacac)2 yields a 1:1 complex as reported in the literature, Pd(O,O-Hfacac)(C-Hfacac)(lutidine), 1. However, when the amount of excess lutidine is increased, a new complex, 2, is formed. A single-crystal X-ray structure of 2 proves it is a rare example of a dimeric palladium complex containing two Pd(Hfacac)(lutidine) fragments bridged by a dianionic trifluoroacetonate ligand, µ-CHC(O)CF3. The formation of 2 is accompanied by a white precipitate determined to be a mixture of trans-Pd(O2CCF3)2(lutidine)2 (3), confirming the fate of the missing trifluoroacetate fragment from the cleavage of the Hfacac ligand, and [lutidinium][Hfacac] (4). Subsequent experiments revealed the determinative role that water played in this reaction. The mechanism of cleavage of the Hfacac ligand was explored by DFT methods.
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Thermosets having low dielectric constant (Dk < 3) and low dielectric dissipation factor (Df < 0.003), high glass transition temperature (Tg > 150 °C), and good adhesion to copper are desirable for the low loss layers of the copper clad laminates (CCL) in next generation printed circuit boards. Three different difunctional diazirines are evaluated for both thermal and photochemical crosslinking of a high Tg vinyl-addition polynorbornene resin: poly(5-hexyl-1-norbornene) (poly(HNB)). The substrate polymer, crosslinked by the carbenes generated from the activated diazirines, forms thermosets with Dk < 2.3 and Df < 0.001 at 10 GHz depending on the identity of the diazirine and the loading. The Dk and Df values for one composition are stable for 1600 h at 125 °C in air and for 1400 h at 85 °C and 85% relative humidity, suggesting good long-term reliability of this thermoset. Adhesion of poly(HNB) to copper can be enhanced by priming the copper surface with a diazirine prior to high temperature lamination; peel strength values of greater than 7.5 N cm-1 are achieved. Negative-tone photopatterning of poly(HNB) with diazirines upon exposure to 365 nm light is demonstrated.
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Permanent junctional reciprocating tachycardia (PJRT) is a rare form of supraventricular tachycardia (SVT) due to a retrograde slow conducting decremental accessory pathway (AP) which is often incessant and can lead to tachycardia-induced cardiomyopathy (TIC). We report the challenging clinical course of a pregnant adolescent with PJRT due to an atypical retrograde slow conducting decremental left posterolateral AP. Pregnancy is known to exacerbate supraventricular arrhythmias and can lead to adverse maternal and fetal outcomes. To the best of our knowledge, there are no prior reports on the clinical course of rare incessant and difficult-to-treat arrhythmias such as PJRT in a pregnant adolescent patient.
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BACKGROUND: Major depressive disorder (MDD) is a leading cause of disease morbidity. Combined treatment with antidepressant medication (ADM) plus psychotherapy yields a much higher MDD remission rate than ADM only. But 77% of US MDD patients are nonetheless treated with ADM only despite strong patient preferences for psychotherapy. This mismatch is due at least in part to a combination of cost considerations and limited availability of psychotherapists, although stigma and reluctance of PCPs to refer patients for psychotherapy are also involved. Internet-based cognitive behaviorial therapy (i-CBT) addresses all of these problems. METHODS: Enrolled patients (n = 3360) will be those who are beginning ADM-only treatment of MDD in primary care facilities throughout West Virginia, one of the poorest and most rural states in the country. Participating treatment providers and study staff at West Virginia University School of Medicine (WVU) will recruit patients and, after obtaining informed consent, administer a baseline self-report questionnaire (SRQ) and then randomize patients to 1 of 3 treatment arms with equal allocation: ADM only, ADM + self-guided i-CBT, and ADM + guided i-CBT. Follow-up SRQs will be administered 2, 4, 8, 13, 16, 26, 39, and 52 weeks after randomization. The trial has two primary objectives: to evaluate aggregate comparative treatment effects across the 3 arms and to estimate heterogeneity of treatment effects (HTE). The primary outcome will be episode remission based on a modified version of the patient-centered Remission from Depression Questionnaire (RDQ). The sample was powered to detect predictors of HTE that would increase the proportional remission rate by 20% by optimally assigning individuals as opposed to randomly assigning them into three treatment groups of equal size. Aggregate comparative treatment effects will be estimated using intent-to-treat analysis methods. Cumulative inverse probability weights will be used to deal with loss to follow-up. A wide range of self-report predictors of MDD heterogeneity of treatment effects based on previous studies will be included in the baseline SRQ. A state-of-the-art ensemble machine learning method will be used to estimate HTE. DISCUSSION: The study is innovative in using a rich baseline assessment and in having a sample large enough to carry out a well-powered analysis of heterogeneity of treatment effects. We anticipate finding that self-guided and guided i-CBT will both improve outcomes compared to ADM only. We also anticipate finding that the comparative advantages of adding i-CBT to ADM will vary significantly across patients. We hope to develop a stable individualized treatment rule that will allow patients and treatment providers to improve aggregate treatment outcomes by deciding collaboratively when ADM treatment should be augmented with i-CBT. TRIAL REGISTRATION: ClinicalTrials.gov NCT04120285 . Registered on October 19, 2019.
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Terapia Cognitivo-Conductual , Trastorno Depresivo Mayor , Antidepresivos/uso terapéutico , Terapia Cognitivo-Conductual/métodos , Trastorno Depresivo Mayor/tratamiento farmacológico , Trastorno Depresivo Mayor/terapia , Humanos , Internet , Atención Primaria de Salud , Resultado del TratamientoRESUMEN
We present the electrocardiographic findings in a 36-year-old female with tricuspid atresia with double-outlet right ventricle and malposition of great arteries who underwent classical or "atriopulmonary" Fontan procedure in childhood. Her electrocardiograms have consistently shown marked intra-atrial delay with an initial positive P wave deflection and terminal negative P deflection in all leads with progressive increase in P wave duration with time. She has had frequent episodes of intra-atrial tachycardia, atrial fibrillation and sinus and post ectopic pauses over the past few years. The findings in our patient, which have not been reported before, illustrate the atrial pathology, which is unique to Fontan physiology, particularly those with classical or atriopulmonary Fontan. We hope that the specific electrocardiographic findings presented will allow for their recognition.
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Procedimiento de Fontan , Atresia Tricúspide , Adulto , Arritmias Cardíacas , Electrocardiografía , Femenino , Atrios Cardíacos/cirugía , Humanos , Atresia Tricúspide/cirugíaRESUMEN
Poly(hydroxystyrene) (PHS) reacts with norbornene in the presence of acid to form a phenoxynorbornane pendent group through the hydroalkoxylation of the norbornene double bond by the phenol -OH group of PHS. Films of PHS, an aqueous base soluble polymer, containing norbornene derivatives and a photoacid generator (PAG) create a negative tone photopatternable composition. Acid generated in the exposed regions of the film promotes the hydroalkoxylation reaction generating the phenoxynorbornane pendent group, rendering the film insoluble in an aqueous base developer. Both dinorbornene and mononorbornene-functional additives were evaluated. In the case of the mononorbornene additive, a unique example of a negative tone photopatterned film that can be reworked after patterning by dissolution in a mild solvent at room temperature was demonstrated. Polymers containing aliphatic alcohol and carboxylic acid pendant functionalities could be photopatterned in the presence of dinorbornene additives showing the generality of this method.
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The norbornenyl gluconamide (NBGA) monomer can be polymerized by a number of palladium catalysts to give water-soluble, vinyl addition poly(NBGA). Depending on the catalyst used, the reaction conditions, and the chain-transfer additives employed, high-molecular-weight polymers can be obtained. These polymers can be thermally cross-linked at ca. 190 °C or at ca. 150 °C when the difunctional glutaraldehyde is added. A photopatternable composition is formed by the addition of a water-soluble diazide when the poly(NBGA) molecular weight is sufficiently high. After image-wise exposure, negative-tone patterns are revealed by water development. A detailed analysis of NBGA monomer structures by high-resolution nuclear magnetic resonance techniques including pure shift is reported showing that two diastereomers of each endo- and exo-isomer are formed from the reaction of norbornene methylamine and δ-gluconolactone.
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OBJECTIVES: To determine if intraoperative aminophylline was superior to furosemide to prevent or attenuate postoperative cardiac surgery-associated acute kidney injury. DESIGN: Single-center, historical control, retrospective cohort study. SETTING: PICU, university-affiliated children's hospital. PATIENTS: Children with congenital heart disease in PICU who received furosemide or aminophylline to treat intraoperative oliguria. INTERVENTIONS: Intraoperative oliguria was treated either with furosemide (September 2007 to February 2012) or with aminophylline (February 2012 to June 2013). The postoperative 48 hours renal outcomes of the aminophylline group were compared with the furosemide group. The primary outcomes were acute kidney injury and renal replacement therapy use at 48 hours postoperatively. Surgical complexity was accounted for by the use of Risk Adjustment for Congenital Heart Surgery-1 score. MEASUREMENTS AND MAIN RESULTS: The study involves 69 months of observation. There were 200 cases younger than 21 years old reviewed for this study. Eighty-five cases (42.5%) developed acute kidney injury. The aminophylline group patients produced significantly more urine (mL/kg/hr) during the first 8 hours postoperatively than furosemide patients (5.1 vs 3.4 mL/kg/hr; p = 0.01). The urine output at 48 hours postoperatively was similar between the two groups. There was no difference in acute kidney injury incidence at 48 hours between the aminophylline and furosemide groups (38% vs 47%, respectively; p = 0.29). Fewer aminophylline group subjects required renal replacement therapy compared to the furosemide group subjects (n = 1 vs 7, respectively; p = 0.03). In the multi-variant predictive model, intraoperative aminophylline infusion was noted as a negative predictive factor for renal replacement therapy, but not for cardiac surgery-associated acute kidney injury. CONCLUSION: The intraoperative use of aminophylline was more effective than furosemide in reversal of oliguria in the early postoperative period. There were less renal replacement therapy-requiring acute kidney injury in children in the aminophylline group. Future prospective studies of intraoperative aminophylline to prevent cardiac surgery-associated acute kidney injury may be warranted.
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Aminofilina/uso terapéutico , Procedimientos Quirúrgicos Cardíacos , Diuréticos/uso terapéutico , Furosemida/uso terapéutico , Cuidados Intraoperatorios/métodos , Complicaciones Intraoperatorias/tratamiento farmacológico , Oliguria/tratamiento farmacológico , Lesión Renal Aguda/epidemiología , Lesión Renal Aguda/etiología , Lesión Renal Aguda/prevención & control , Lesión Renal Aguda/terapia , Adolescente , Niño , Preescolar , Femenino , Estudios de Seguimiento , Cardiopatías Congénitas/cirugía , Humanos , Incidencia , Lactante , Recién Nacido , Masculino , Oliguria/etiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/terapia , Terapia de Reemplazo Renal , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenAsunto(s)
Consenso , Manejo de la Enfermedad , Revascularización Miocárdica/métodos , Taquicardia Ventricular , Función Ventricular/fisiología , Niño , Electrocardiografía , Humanos , Pronóstico , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatología , Taquicardia Ventricular/terapiaRESUMEN
INTRODUCTION: Sudden death, particularly when occurring in children and adolescents, is a traumatic event not only for the victim's family, but for the entire community. It has been shown that school-based automated external defibrillator (AED) programs provide a high survival rate for both students and nonstudents who suffer sudden cardiac arrest (SCA) on school grounds. The use of AEDs is becoming increasingly more common in schools in the United States. In West Virginia middle and high schools, we analyzed the prevalence and use of AEDs, barriers to obtaining a device, and cases of sudden death on school grounds. METHODS: A mailed survey distributed to West Virginia high schools and middle schools collected general demographic data, AED data, and occurrences of sudden death on school grounds. Schools reporting a death were contacted to obtain details regarding the event. For schools with a device, the number of AEDs, length of possession, reasons for and means of obtaining the AED, personnel trained to operate the AED and the number of device uses were determined. For schools without an AED, barriers to and interest in obtaining a device were determined. RESULTS: Two hundred and twenty-five of 312 surveys (72%) were returned. One hundred and fifty-two schools (68%) currently have at least one AED and 73 schools (32%) do not have an AED. Public high schools had the highest prevalence of AEDs (76%) compared to public middle schools (62%) and private schools (67%). Sixty-nine percent of schools obtained their devices by donations or grants and 32% obtained them using school funds. Barriers to obtaining a device included cost (82%), lack of trained personnel (45%), unfamiliarity with AED (22%), and liability issues (19%). There were a total of 23 deaths on school premises reported by 20 schools. There was one reported occurrence of an AED being used to save a life. CONCLUSION: Over two thirds of West Virginia middle schools and high schools currently have at least one AED on their premises. An AED is an effective way of preventing death following sudden cardiac arrest, and has saved at least one life in a West Virginia school. While most schools without AEDs cite cost as the main deterrent, the majority of schools with a device received them via donation or grant. We submit that a number of sudden deaths on West Virginia school grounds could possibly have been averted by use of an AED.
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Desfibriladores/estadística & datos numéricos , Instituciones Académicas/estadística & datos numéricos , Adolescente , Adulto , Niño , Estudios Transversales , Muerte Súbita Cardíaca/prevención & control , Humanos , Capacitación en Servicio/estadística & datos numéricos , Persona de Mediana Edad , West Virginia , Adulto JovenRESUMEN
We evaluated the presentation, treatment, and outcome of infants who present with ventricular tachycardia in the first year of life. Seventy-six infants were admitted to our institution with a diagnosis of ventricular tachycardia between January, 1987 and May, 2006. Forty-five infants were excluded from the study because of additional confounding diagnoses including accelerated idioventricular rhythm, Wolff-Parkinson-White syndrome, supraventricular tachycardia with aberrancy, long QT syndrome, cardiac rhabdomyoma, myocarditis, congenital lesions, or incomplete data. The remaining 31 included infants who had a median age at presentation of 1 day, with a range from 1 to 255 days, and a mean ventricular tachycardia rate of 213 beats per minute, with a range from 171 to 280, at presentation. The infants were treated chronically with propranolol (38.7%), amiodarone (12.9%), mexiletine (3.2%), propranolol and mexiletine (9.7%), or propranolol and procainamide (6.5%). The median duration of treatment was 13 months, with a range from 3 to 105 months. Ventricular tachycardia resolved spontaneously in all infants. No patient died, or received catheter ablation or device therapy. Median age at last ventricular tachycardia was 59 days, with a range from 1 to 836 days. Mean follow-up was 45 months, with a range from 5 to 164 months, with a mean ventricular tachycardia-free period of 40 months. Infants with asymptomatic ventricular tachycardia, a structurally normal heart, and no additional electrophysiological diagnosis all had spontaneous resolution of tachycardia. Furthermore, log-rank analysis of the time to ventricular tachycardia resolution showed no difference between children who received chronic outpatient anti-arrhythmic treatment and those who had no such therapy. While indications for therapy cannot be determined from this study, lack of symptoms or myocardial dysfunction suggests that therapy may not be necessary.
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Antiarrítmicos/uso terapéutico , Taquicardia Ventricular/tratamiento farmacológico , Ecocardiografía , Electrocardiografía , Electrocardiografía Ambulatoria , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Remisión Espontánea , Análisis de Supervivencia , Taquicardia Ventricular/fisiopatologíaRESUMEN
An infant of a diabetic mother with a prenatal diagnosis of tetralogy of Fallot and tricuspid atresia is presented. To the best of the authors' knowledge, this is the first report of such an association.
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Diabetes Mellitus Tipo 2/complicaciones , Complicaciones del Embarazo , Tetralogía de Fallot/diagnóstico por imagen , Atresia Tricúspide/diagnóstico por imagen , Adulto , Procedimientos Quirúrgicos Cardíacos/métodos , Diagnóstico Diferencial , Femenino , Estudios de Seguimiento , Humanos , Recién Nacido , Embarazo , Tetralogía de Fallot/cirugía , Atresia Tricúspide/cirugía , UltrasonografíaRESUMEN
OBJECTIVE: Risk factors for poor outcome with congenital complete heart block include prematurity, low birth weight, hydrops, low ventricular rates, and congenital heart disease. In this group, medical therapy is often ineffective, pacing is technically challenging, and mortality exceeds 80%. The purpose of this study is to assess outcomes of patients with congenital complete heart block who were paced in the first 24 hours after birth owing to the presence of known risk factors. METHODS: We performed a retrospective review of patients with congenital complete heart block paced in the first 24 hours after birth at our institution between November 1, 1995, and July 31, 2007. RESULTS: Thirteen patients were identified, 4 of whom had heterotaxy syndrome. Eleven patients had temporary epicardial pacing wires placed; 2 received permanent pacemakers as the initial mode of pacing. There were 7 deaths (54% mortality) at a mean age of 19.9 +/- 19 days. Among 7 patients with structural heart disease, there was 1 survivor. Among 6 patients with structurally normal hearts, there were 5 survivors (P = .025). Patients with temporary wires who survived to permanent pacemaker implantation (6/11) used their temporary leads for 33.8 +/- 18.3 days. CONCLUSIONS: In the severely affected fetus with congenital complete heart block and significant structural heart disease, outcomes remain poor; however, neonates with congenital complete heart block and structurally normal hearts who are monitored antenatally and delivered in a planned fashion at an institution capable of early pacing can have favorable outcomes. The use of temporary pacing wires is an option in the management of these patients.
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Estimulación Cardíaca Artificial , Bloqueo Cardíaco/congénito , Bloqueo Cardíaco/terapia , Estimulación Cardíaca Artificial/métodos , Femenino , Bloqueo Cardíaco/mortalidad , Humanos , Recién Nacido , Masculino , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Ventricular tachycardia (VT) in patients following tetralogy of Fallot (TOF) repair is challenging to map because of the presence of scar, patch material, and hemodynamic residua of surgery. This study investigates whether noncontact mapping can identify the arrhythmia substrate in a porcine model that involves a right ventricular outflow tract (RVOT) patch and either chronic volume or pressure load on the right ventricle. METHODS: Nine infant pigs (3-5 kg) underwent surgery involving an RVOT patch and creation of pulmonary insufficiency (PI, n = 4) or pulmonary stenosis (PS, n = 5). After a mean of 4.2 months, pigs underwent invasive electrophysiology studies (EPS) with noncontact mapping (Ensite, St. Jude Medical, St. Paul, MN USA) of the right ventricle. Automated, unipolar voltage maps (VM) were constructed during sinus rhythm. Threshold for substrate was set at -0.5 mV and incrementally adjusted to higher values until a contiguous region of low voltage was delineated. Programmed stimulation was performed to induce VT. VT activation was correlated to location of VM defined substrate. Three control pigs underwent EPS and VM. RESULTS: Free-wall RVOT substrate was identified in each of the model animals, correlating to location of the patch. The mean voltage threshold was -1.1 mV. VT was induced in 6/9 animals. Diastolic activation approximated the inferior or lateral border of the substrate in all animals. No RVOT substrate was identified in the control pigs. CONCLUSION: Automated voltage mapping of sinus beats identifies substrate for VT in a porcine model of TOF. Consistent diastolic activation of the substrate border was found during VT. Targeting this area may be useful in the ablation of VT after repair of TOF.
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Mapeo del Potencial de Superficie Corporal/métodos , Modelos Animales de Enfermedad , Sistema de Conducción Cardíaco/fisiopatología , Taquicardia Ventricular/etiología , Taquicardia Ventricular/fisiopatología , Tetralogía de Fallot/complicaciones , Tetralogía de Fallot/fisiopatología , Animales , PorcinosRESUMEN
BACKGROUND: Novel nontransvenous implantable cardioverter defibrillator (ICD) configurations are sometimes required for small children and children with complex congenital heart disease at risk for sudden death. Mid- to long-term follow-up of these nontraditional implant techniques is not well known. We assessed the mid-term performance of a subcutaneous lead technique used in our practice. METHODS: Between July 2002 and November 2003, 4 patients (age 2.1-8.5 years, weight 13-33.3 kg, height 90-126.7 cm) received an ICD with a single-finger (n = 3) or 2-finger (n = 1) subcutaneous array with an active abdominal can and epicardial pace/sense lead. The subcutaneous tunnel was created via a subxiphoid incision using a tunneling tool within a sheath along the seventh intercostal space and extended posterior to the spine. Diagnoses included long QT syndrome (n = 2), idiopathic ventricular fibrillation (n = 1), and idiopathic dilated cardiomyopathy (n = 1). Implantable cardioverter defibrillator indications included syncope (n = 2) and cardiac arrest (n = 2). RESULTS: Mean follow-up was 22.3 +/- 13.9 months. During follow-up, 1 patient underwent heart transplantation and the other 3 patients underwent generator replacement secondary to a manufacturer's advisory. There was 1 appropriate and successful shock for ventricular fibrillation. This patient experienced a second episode of ventricular fibrillation that the ICD discharge failed to terminate. The arrhythmia spontaneously resolved. There were no inappropriate shocks. There was 1 instance of false detection of ventricular fibrillation because of intermittent T wave oversensing but therapy was not administered. There were no infections, lead fractures, or other complications during follow-up. CONCLUSION: This novel nontransvenous ICD configuration can be used safely in a select group of pediatric patients and allows for the applicability of this life-saving technology to small children at high risk for sudden cardiac death.
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Desfibriladores Implantables , Cardiomiopatía Dilatada/terapia , Niño , Preescolar , Errores Diagnósticos , Instalación Eléctrica , Diseño de Equipo , Reacciones Falso Positivas , Estudios de Seguimiento , Humanos , Síndrome de QT Prolongado/terapia , Resultado del Tratamiento , Fibrilación Ventricular/diagnóstico , Fibrilación Ventricular/fisiopatología , Fibrilación Ventricular/terapiaRESUMEN
Esmolol is often used in the acute management of children with arrhythmias and/or hypertension; however, pharmacokinetic studies of the drug in children have been limited. The objective of this study was to determine the pharmacokinetics of esmolol in children with a history of supraventricular arrhythmias (SVT) who were scheduled for diagnostic electrophysiology study or a catheter ablation procedure. Subjects were stratified into two age groups: 2-11 and 12-16 years. After an episode of stimulated or spontaneous SVT, esmolol was administered intravenously as a 1,000 microg/kg bolus followed by continuous infusion at 300 microg/kg/min. Blood samples were collected before, at 5, 10 and 15 min after the loading dose, and 3, 6, 9, 12, 15 and 20 min after the end of the infusion. Plasma concentration of esmolol was quantitated by a specific LC/MS assay. Pharmacokinetic data were available for 25 subjects. Arterial esmolol concentrations were approximately five times greater than venous concentrations. Esmolol had an extremely short distribution half-life (0.6 min), a rapid terminal elimination half-life (6.9 min), and a rapid clearance (119 +/- 51 mL/min/kg) which was not related to subject age or weight. Seventeen of the subjects (63%) converted to normal sinus rhythm in an average of 2 min (range 0-5 min). The pharmacokinetics of esmolol and its efficacy in terminating SVT in children is similar to that observed in adults.
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Antagonistas Adrenérgicos beta/farmacocinética , Propanolaminas/farmacocinética , Taquicardia Supraventricular/tratamiento farmacológico , Adolescente , Antagonistas Adrenérgicos beta/administración & dosificación , Antagonistas Adrenérgicos beta/sangre , Presión Sanguínea/efectos de los fármacos , Ablación por Catéter , Niño , Preescolar , Técnicas Electrofisiológicas Cardíacas , Femenino , Semivida , Sistema de Conducción Cardíaco/efectos de los fármacos , Sistema de Conducción Cardíaco/fisiopatología , Sistema de Conducción Cardíaco/cirugía , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Infusiones Intravenosas , Masculino , Propanolaminas/administración & dosificación , Propanolaminas/sangre , Taquicardia Supraventricular/fisiopatología , Taquicardia Supraventricular/cirugía , Resultado del Tratamiento , Estados UnidosRESUMEN
There are approximately 800,000 adult survivors of congenital heart disease in the U.S., and this number continues to increase on an annual basis. It was only 50 years ago that the first intracardiac repair of a congenital heart defect was performed. Survival into adulthood has only been realistic in the last three decades. This has created a new patient population with a number of challenges such as the impact of adult onset diseases on their underlying cardiac pathology, cognitive, physical, and psychosocial development, as well as issues related to reproduction, employment and health insurance. Possibly the most significant obstacle is identifying healthcare professionals who can provide long-term care. This manuscript reviews the challenges and recommendations for the care of these patients.
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Cardiopatías Congénitas/cirugía , Grupo de Atención al Paciente , Adulto , Factores de Edad , Continuidad de la Atención al Paciente , Cardiopatías Congénitas/complicaciones , Cardiopatías Congénitas/mortalidad , Humanos , SobrevivientesRESUMEN
BACKGROUND: Altered cardiac autonomic control may play a role in the morbidity and mortality suffered by neonates who undergo surgery for complex congenital heart disease (CHD). The purpose of this study was to evaluate cardiac autonomic activity, as measured by spectral indices of heart rate variability (HRV), prior to and early after infant surgery for CHD and attempt to correlate HRV indices with clinical outcome. In addition, we assessed the hypothesis that single-ventricle physiology and surgical interruption of the great arteries negatively affects HRV. METHODS: Sixty neonates prospectively wore 24-hour Holter monitors at three time points: before and early after CHD surgery, and at 3- to 6-month follow-up. Standard spectral indices of HRV were measured. RESULTS: In the early postoperative time point, patients with single-ventricle physiology had lower low-frequency power (LF) compared to patients with two ventricles (P=0.040). Surgical interruption of the great arteries did not affect HRV in this cohort. For the entire cohort, LF (P=0.004) and high-frequency power (HF) (P<0.001) increased over the three time points, while LF/HF (P=0.119) did not significantly change. In the multivariable linear regression model, significant predictors of longer postoperative hospital stay included longer total support time (P=or<0.001), longer duration of inotrope support (P=0.012), elevated mean heart rate at postoperative time point (P=0.002), and lower LF/HF ratio at the postoperative time point (P=0.014). CONCLUSION: Patients with single-ventricle physiology have a significant physiologic reduction in LF in the early postoperative period compared to patients with two ventricles. Diminished cardiac autonomic control is associated with longer hospitalization following neonatal cardiac surgery.
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Arritmias Cardíacas/fisiopatología , Arritmias Cardíacas/cirugía , Electrocardiografía Ambulatoria , Cardiopatías Congénitas/fisiopatología , Cardiopatías Congénitas/cirugía , Frecuencia Cardíaca , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/etiología , Estudios de Cohortes , Femenino , Cardiopatías Congénitas/complicaciones , Cardiopatías Congénitas/diagnóstico , Humanos , Recién Nacido , Masculino , Resultado del TratamientoRESUMEN
Cardiac magnetic resonance (CMR) has been helpful in adults in the diagnosis of arrhythmogenic right ventricular dysplasia. Short of direct surgical observation or autopsy, no gold standard exists. CMR diagnostic criteria include right atrial and ventricular dilation, regional right ventricular (RV) wall motion abnormalities, outflow tract ectasia, and myocardial fatty infiltration. To determine whether adult diagnostic criteria are useful in children referred for CMR for this diagnosis, the images and records of 81 patients (aged 11.5 +/- 5.5 years) over an 8-year period were reviewed. Histories included ventricular tachycardia, palpitations, dilated right ventricle, syncope, near sudden death, or family history of RV dysplasia. Four families were studied with parents who had RV dysplasia diagnosed by surgery, explanted heart, or CMR. CMR imaging included T1-weighted imaging, cine, 1-dimensional RV myocardial tagging, and phase-encoded velocity mapping, and 2 patients underwent delayed-enhancement CMR. Only 1 of the 81 patients met 5 of the criteria. None of the others met >2 of the criteria, and only 2 patients met 1 or 2 criteria. For questionable regional wall motion abnormalities, RV myocardial tagging was helpful. In conclusion, CMR of patients with a history suspicious for the diagnosis of RV dysplasia is a low-yield test in children. This may be due to the evolving nature of the disease, which does not manifest itself from a morphologic or ventricular-function standpoint until later in development. Follow-up studies as patients age may be advantageous.