RESUMEN
OBJECTIVES: To report our experience with fetal diagnosis of right aortic arch (RAA) variants based on the ductus arteriosus (DA) anatomy and brachiocephalic vessel branching pattern in relation to the trachea, and to establish whether the echocardiographic 'V-shaped' or 'U-shaped' appearance of the junction between the DA and aortic arch (AA) in the fetal upper mediastinal view is sufficiently accurate for assessment of fetal AA anatomy. METHODS: This was a retrospective study of pregnancies with a prenatal diagnosis of fetal RAA that had postnatal confirmation of AA anatomy, referred to our tertiary center during 2011-2017. Prenatal and postnatal medical records, including echocardiographic and computed tomography (CT)/magnetic resonance imaging (MRI) scan reports, were reviewed, and cardiac and extracardiac abnormalities and the results of genetic testing were recorded. RESULTS: Of 55 consecutive pregnancies with a prenatal diagnosis of fetal RAA, six were lost to follow-up, one was terminated and three were excluded due to lack of postnatal confirmation of AA anatomy. Of the remaining 45 pregnancies, AA anatomy was assessed postnatally by CT in 39, by MRI in one and by direct examination at cardiac surgery in five. A U-shaped appearance was found in 37/45 (82.2%) patients, all of which had a complete vascular ring (CVR). Of these 37 patients, on postnatal confirmation, 21 (56.8%) had RAA with Kommerell's diverticulum, left posterior ductus arteriosus (LPDA) and aberrant left subclavian artery (ALSA) (RAA/LPDA/ALSA), 11 (29.7%) had a double AA (DAA), four (10.8%) had RAA with Kommerell's diverticulum, LPDA and mirror-image (MI) branching (RAA/LPDA/MI), and one (2.7%) had RAA with Kommerell's diverticulum, LPDA and aberrant left innominate artery (ALIA) (RAA/LPDA/ALIA). A V-shaped appearance was found in 3/45 (6.7%) patients, all of which had RAA with right DA not forming a CVR and MI branching. In the 5/45 (11.1%) fetuses with neither U- nor V-shaped appearance, RAA with left anterior DA arising from the left innominate artery and MI branching, not forming a CVR, was found. Twelve (26.7%) fetuses had a congenital heart defect (CHD). RAA forming a CVR (U-shaped appearance) was associated with a septal defect in 6/37 (16.2%) fetuses, while RAA not forming a CVR (V-shaped appearance or no U- or V-shaped appearance) was associated with major CHD in 6/8 (75.0%) fetuses. CONCLUSIONS: In fetuses with RAA, V-shaped appearance of the junction between the DA and AA indicates only that the transverse AA and DA run together on the same side of the thorax (trachea) while a U-shaped appearance is always a sign of a CVR. Among fetuses with a CVR, RAA/LPDA/MI is more frequent than described previously. Finally, RAA forming a CVR is not usually associated with complex CHD, as opposed to RAA not forming a CVR. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Aorta Torácica/diagnóstico por imagen , Síndromes del Arco Aórtico/diagnóstico por imagen , Ecocardiografía/métodos , Corazón Fetal/anomalías , Diagnóstico Prenatal/normas , Adulto , Aorta Torácica/anomalías , Síndromes del Arco Aórtico/patología , Anomalías Cardiovasculares/diagnóstico por imagen , Conducto Arterial/diagnóstico por imagen , Femenino , Enfermedades Fetales/diagnóstico por imagen , Corazón Fetal/diagnóstico por imagen , Pruebas Genéticas/métodos , Edad Gestacional , Cardiopatías Congénitas/diagnóstico por imagen , Cardiopatías Congénitas/epidemiología , Cardiopatías Congénitas/patología , Humanos , Imagen por Resonancia Magnética/métodos , Atención Posnatal/estadística & datos numéricos , Embarazo , Diagnóstico Prenatal/métodos , Estudios Retrospectivos , Arteria Subclavia/anomalías , Arteria Subclavia/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Ultrasonografía Prenatal/estadística & datos numéricos , Anillo Vascular/diagnóstico por imagen , Anillo Vascular/patologíaRESUMEN
OBJECTIVE: Pulmonary atresia with intact ventricular septum (PAIVS) is a rare cardiac malformation with a broad spectrum of anatomical manifestations, varying from types suitable for biventricular repair to those with diminutive right ventricle and primitive ventriculocoronary connections (VCC), more suitable for single-ventricle palliation or heart transplantation. We sought to test whether tricuspid regurgitation is an easily detectable prenatal criterion with which to identify PAIVS patients at lower risk of needing postnatal single-ventricle palliation. METHOD: We identified retrospectively patients with both fetal diagnosis and postnatal confirmation of PAIVS who were seen at Bambino Gesù Hospital between January 2000 and December 2006. Tricuspid valve/mitral valve (TV/MV) ratio, presence and severity of tricuspid regurgitation and direct visualization of VCC were evaluated by echocardiography both pre- and postnatally. RESULTS: We identified 22 patients with a prenatal diagnosis of PAIVS. Four pregnancies were terminated and one fetus was lost to follow-up, leaving 17 patients for the analysis. Based on postnatal cardiac catheterization and/or echocardiography we divided our population in two groups: Group 1 included 10 patients with VCC; Group 2 included seven patients without VCC. At fetal echocardiography, tricuspid regurgitation was absent in all ten Group 1 patients and present in all seven Group 2 patients. VCC were seen directly in 6/10 Group 1 patients and in no Group 2 patients. A cut-off value of 0.56 for the TV/MV ratio was highly predictive of VCC during fetal life, with a sensitivity of 100% and a specificity of 90%. CONCLUSIONS: The absence of tricuspid regurgitation in fetuses affected by PAIVS is a strong prenatal echocardiographic predictor of VCC, as is a TV/MV ratio < 0.56. Fetuses presenting with tricuspid regurgitation and relatively large right ventricle are at lower risk of needing single-ventricle palliation postnatally. This inforation could be helpful for appropriate prenatal counseling and postnatal decision-making.
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Anomalías de los Vasos Coronarios/diagnóstico por imagen , Complicaciones Cardiovasculares del Embarazo/diagnóstico por imagen , Atresia Pulmonar/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Anomalías de los Vasos Coronarios/patología , Femenino , Humanos , Italia , Embarazo , Atresia Pulmonar/complicaciones , Estudios Retrospectivos , Sensibilidad y Especificidad , Insuficiencia de la Válvula Tricúspide/complicaciones , Ultrasonografía Doppler en Color , Ultrasonografía Doppler de Pulso , Ultrasonografía Prenatal , Tabique Interventricular/diagnóstico por imagenRESUMEN
Ebstein's anomaly is a rare congenital heart defect. Associated lesions are uncommon, and the mortality rates can be as high as 54% during the first month of life. Two cases of severe Ebstein's anomaly with ventricular septal defect are described. It is speculated that this rare association, allowing adequate forward pulmonary blood flow in the neonate, permitted the reported patients to survive the neonatal period, which is the most life-threatening time. The authors propose that the presence of a small ventricular septal defect can be beneficial for such patients, averting the need for surgery during early infancy when the risk is highest.
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Anomalía de Ebstein/epidemiología , Defectos del Tabique Interventricular/epidemiología , Comorbilidad , Circulación Coronaria , Anomalía de Ebstein/sangre , Anomalía de Ebstein/diagnóstico por imagen , Anomalía de Ebstein/fisiopatología , Electrocardiografía , Femenino , Defectos del Tabique Interventricular/sangre , Defectos del Tabique Interventricular/diagnóstico por imagen , Defectos del Tabique Interventricular/fisiopatología , Humanos , Lactante , Oxígeno/sangre , UltrasonografíaAsunto(s)
Enfermedades Cardiovasculares/tratamiento farmacológico , Ensayos Clínicos como Asunto/normas , Drogas en Investigación/efectos adversos , Determinación de Punto Final , Enfermedad Aguda , Niño , Protección a la Infancia , Enfermedad Crónica , Cardiopatías Congénitas/tratamiento farmacológico , HumanosRESUMEN
Infection of asthmatics with human rhinovirus (HRV) enhances airway eosinophilia and airways hyperreactivity. The current studies were performed to further characterize HRV-induced generation by human bronchial epithelial cells of granulocyte macrophage colony-stimulating factor (GM-CSF), a cytokine that could contribute to airway eosinophilia by increasing the survival and activation of eosinophils, and to determine the effects of the antiviral agent nitric oxide (NO) on HRV-induced GM-CSF production. Maximal levels of messenger RNA (mRNA) for GM-CSF were seen 1 h after HRV infection. Expression was sustained through 24 h and declined by 48 h. GM-CSF protein was detected in cell supernatants by 2 h after infection and reached maximal concentrations by 24 h, with the most rapid rate of production occurring from 2 to 7 h. The NO donor 3-(2-hydroxy-2-nitroso-1-propyl-hydrazino)-1-propanamine (NONOate) inhibited HRV-induced GM-CSF protein production in a time- and dose-dependent fashion. NONOate also inhibited HRV-induced GM-CSF mRNA levels at both times (1 and 4 h) examined. NONOate increased GM-CSF mRNA stability, suggesting that reduced mRNA levels were due to inhibition of transcription. The transcription factor nuclear factor-kappa B was rapidly induced by HRV infection, but was not inhibited by NONOate, implying a role for other transcription factors. Thus, NO may play an important anti-inflammatory role in virally induced exacerbations of diseases such as asthma.
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Bronquios/fisiología , Regulación de la Expresión Génica/fisiología , Factor Estimulante de Colonias de Granulocitos y Macrófagos/genética , Donantes de Óxido Nítrico/farmacología , Óxido Nítrico/fisiología , Mucosa Respiratoria/fisiología , Mucosa Respiratoria/virología , Rhinovirus/fisiología , Animales , Bronquios/virología , Línea Celular , Células Cultivadas , Citocinas/genética , Regulación de la Expresión Génica/efectos de los fármacos , Factor Estimulante de Colonias de Granulocitos y Macrófagos/biosíntesis , Humanos , Cinética , Proteínas Nucleares/metabolismo , ARN Mensajero/genética , Mucosa Respiratoria/efectos de los fármacos , Rhinovirus/efectos de los fármacos , Factores de Tiempo , Replicación Viral/efectos de los fármacosRESUMEN
Infants with coarctation of the aorta may have obstructions at other sites within the left heart which are not always apparent on the initial echocardiogram. The magnitude of the risk of having the additional obstructions is not well described, with few reliable quantitative criterions for identifying patients at the highest risk. We determined the frequency of additional, late appearing, stenotic lesions within the left heart, and the predictive morphologic features on the initial cross-sectional echocardiogram. We identified all patients with coarctation of the aorta diagnosed by 3 months of age, excluding those with complex cardiac disease or definite additional stenotic lesions at presentation, leaving 101 patients for study. At follow-up, 31 stenotic lesions were diagnosed in 23 patients, 15 of whom had at least 1 intervention. Mitral stenosis was diagnosed in 11 patients, aortic stenosis in 10, subaortic stenosis in 8, and supravalvar aortic stenosis in 2. The probability for freedom from obstructive lesions was 81% at 1 year, 74% at 3 years, and 70% at 5 years. Echocardiographic predictors of mitral stenosis included smaller mitral valvar annuluses, presence of a mean transmitral gradient between 2.5 and 5.0 mmHg, and elongation of the area of intervalvar fibrous continuity. Predictors of aortic stenosis were smaller mitral valvar annuluses, an initial aortic valvar gradient between 15 and 20 mmHg, and obliteration of the commissure between the right and non-coronary leaflets of the aortic valve. Predictors of subaortic stenosis were smaller mitral valvar annuluses and elongation of the area of intervalvar fibrous continuity. Patients with Z-scores for the diameter of the mitral valve of less than -1 were at the highest risk for manifesting obstructive lesions at any level. Associated stenoses in the left heart are common in the setting of aortic coarctation. When Doppler data is equivocal, features of the cross-sectional echocardiogram can identify the sub-group of infants at increased risk.
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Coartación Aórtica/complicaciones , Estenosis de la Válvula Aórtica/etiología , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Mitral/etiología , Estenosis de la Válvula Mitral/mortalidad , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Baltimore/epidemiología , Ecocardiografía Doppler , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Registros Médicos , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estudios Retrospectivos , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
BACKGROUND: Human rhinovirus (HRV) infections are the predominant cause of the common cold and are associated with exacerbations of asthma. Nitric oxide (NO) may play an important role in host defense by means of its potent antiviral properties. OBJECTIVE: We sought to determine whether epithelial expression of type 2 nitric oxide synthase (NOS 2), which produces NO, is induced on rhinovirus infection in vitro and in vivo. METHODS: Primary cultures of human airway epithelial cells were infected with HRV-16, and NOS 2 mRNA expression was assessed by conventional and real-time RT-PCR and NOS 2 protein by using Western blot analysis. Human subjects were also infected with HRV-16 in vivo, and mRNA for NOS 2 was assessed in nasal epithelial scrapings obtained before and after infection. RESULTS: NOS 2 mRNA levels increased within 8 hours after HRV-16 infection of cultured cells and remained elevated up to 48 hours after infection. NOS 2 protein was elevated at 24 hours. Induction of NOS 2 did not occur with UV-inactivated HRV-16 but could be reproduced by using double-stranded RNA, indicating that induction was dependent on viral replication. Increased NOS 2 expression was also observed in nasal epithelial scrapings during symptomatic colds. CONCLUSION: Increased epithelial expression of NOS 2 mRNA occurs as part of the host response to HRV infection in vitro and in vivo. Given the antiviral effects of NO, we speculate that increased host production of NO may play an important role in host defense during HRV infections.
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Bronquios/citología , Resfriado Común/fisiopatología , Células Epiteliales/enzimología , Óxido Nítrico Sintasa/biosíntesis , Rhinovirus , Bronquios/enzimología , Expresión Génica , Humanos , Técnicas In Vitro , Masculino , Mucosa Nasal/citología , Mucosa Nasal/enzimología , Óxido Nítrico Sintasa/genética , Óxido Nítrico Sintasa de Tipo II , ARN Bicatenario/farmacología , ARN Mensajero/metabolismo , Reacción en Cadena de la Polimerasa de Transcriptasa InversaRESUMEN
BACKGROUND: Endocardial function indexes overestimate myocardial fiber shortening, a geometric effect proportional to wall thickness. We hypothesized that elevated endocardial indexes of left ventricular contractile function after repair of isolated coarctation of the aorta could be related to this effect. METHODS: Chamber dimensions and wall thickness were measured from 59 echocardiograms in 57 patients aged 1.2 to 32 years, 8.5 +/- 5.6 years after coarctation repair, and in 305 normal controls aged 1 to 35 years. Midwall and endocardial shortening indexes and end-systolic fiber stress were calculated. The stress-velocity index (SVI), a load-independent index of contractility, was derived from these variables. All values were expressed as z scores. RESULTS: After coarctation repair, the midwall-derived SVI was elevated, but significantly less so than the endocardial-derived SVI (0.6 +/- 1.6 vs 1.3 +/- 2.6; P =.01). The endocardial-derived SVI correlated with the end-systolic thickness/dimension ratio (P <.0001), but the midwall-derived SVI did not. There was no linear relation between the midwall-derived SVI and the residual blood pressure gradient. The mean midwall-derived SVI was higher compared with the normal population in those with a minor residual blood pressure gradient (15 mm Hg), but this achieved statistical significance only in the latter group (0.5 +/- 1.6, P =.08; and 0.8 +/- 1.7, P =.03, respectively). CONCLUSIONS: Endocardial indexes of function and contractility overestimate fiber shortening after coarctation repair. Nevertheless, midwall shortening indexes demonstrate enhanced contractility, particularly in those with residual coarctation.
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Coartación Aórtica/cirugía , Endocardio/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Contracción Miocárdica/fisiología , Función Ventricular Izquierda/fisiología , Adolescente , Adulto , Envejecimiento/fisiología , Coartación Aórtica/diagnóstico por imagen , Coartación Aórtica/fisiopatología , Velocidad del Flujo Sanguíneo/fisiología , Niño , Preescolar , Ecocardiografía Doppler , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Lactante , Recién Nacido , Presión Ventricular/fisiologíaRESUMEN
BACKGROUND: This study was designed to determine if vertically transmitted HIV infection and maternal infection with HIV are associated with altered cardiovascular structure and function in utero. METHODS: Fetal echocardiography was performed in 173 fetuses of 169 HIV-infected mothers (mean gestational age, 33.0 weeks; SD = 3.7 weeks) at 5 centers. Biparietal diameter, femur length, cardiovascular dimensions, and Doppler velocities through atrioventricular and semilunar valves and the umbilical artery were measured. Measurements were converted to z scores based on published normal data. RESULTS: Fetuses determined after birth to be HIV-infected had similar echocardiographic findings as fetuses later determined to be HIV-uninfected except for slightly smaller left ventricular diastolic dimensions (P =.01). The femur length (P =.03) was also smaller in the fetuses postnatally identified as HIV-infected. Differences in cardiovascular dimensions and Doppler velocities were identified between fetuses of HIV-infected women and previously published normal fetal data. The reason for the differences may be a result of maternal HIV infection, maternal risk factors, or selection bias in the external control data. CONCLUSIONS: Vertically transmitted HIV infection may be associated with reduced left ventricular size but not with altered cardiac function in utero. Fetuses of HIV-infected mothers may have abnormal cardiovascular structure and function and increased placental vascular resistance, regardless of whether the fetuses are subsequently found to be infected with HIV.
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Ecocardiografía Doppler , Corazón Fetal/diagnóstico por imagen , Infecciones por VIH/diagnóstico por imagen , Transmisión Vertical de Enfermedad Infecciosa , Ultrasonografía Prenatal/métodos , Adulto , Velocidad del Flujo Sanguíneo/fisiología , Femenino , Corazón Fetal/fisiopatología , Edad Gestacional , VIH/inmunología , Anticuerpos Anti-VIH/análisis , Infecciones por VIH/transmisión , Infecciones por VIH/virología , Cardiopatías Congénitas/diagnóstico por imagen , Cardiopatías Congénitas/etiología , Cardiopatías Congénitas/fisiopatología , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Humanos , Exposición Materna , Contracción Miocárdica/fisiología , Embarazo , Resultado del Embarazo , Pronóstico , Estudios ProspectivosRESUMEN
Infection of human epithelial cells with human rhinovirus (HRV)-16 induces rapid production of several proinflammatory cytokines, including IL-8, IL-6, and GM-CSF. We evaluated the role of NF-kappaB in HRV-16-induced IL-8 and IL-6 production by EMSA using oligonucleotides corresponding to the binding sites for NF-kappaB in the IL-6 and IL-8 gene promoters. Consistent with the rapid induction of mRNA for IL-8 and IL-6, maximal NF-kappaB binding to both oligonucleotides was detected at 30 min after infection. NF-kappaB complexes contained p65 and p50, but not c-Rel. The IL-8 oligonucleotide bound recombinant p50 with only about one-tenth the efficiency of the IL-6 oligonucleotide, even though epithelial cells produced more IL-8 protein than IL-6. Neither the potent glucocorticoid, budesonide (10-7 M), nor a NO donor inhibited NF-kappaB binding to either cytokine promoter or induction of mRNA for either IL-8 or IL-6. Sulfasalazine and calpain inhibitor I, inhibitors of NF-kappaB activation, blocked HRV-16-induced formation of NF-kappaB complexes with oligonucleotides from both cytokines, but did not inhibit mRNA induction for either cytokine. By contrast, sulfasalazine clearly inhibited HRV-16 induction of mRNA for GM-CSF in the same cells. Thus, HRV-16 induces epithelial expression of IL-8 and IL-6 by an NF-kappaB-independent pathway, whereas induction of GM-CSF is at least partially dependent upon NF-kappaB activation.
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Bronquios/inmunología , Bronquios/metabolismo , Citocinas/biosíntesis , Células Epiteliales/inmunología , Células Epiteliales/metabolismo , FN-kappa B/fisiología , Rhinovirus/inmunología , Bronquios/efectos de los fármacos , Bronquios/virología , Budesonida/farmacología , Calpaína/antagonistas & inhibidores , Línea Celular , Citocinas/genética , Células Epiteliales/efectos de los fármacos , Células Epiteliales/virología , Glicoproteínas/farmacología , Factor Estimulante de Colonias de Granulocitos y Macrófagos/biosíntesis , Factor Estimulante de Colonias de Granulocitos y Macrófagos/genética , Humanos , Interleucina-6/biosíntesis , Interleucina-6/genética , Interleucina-6/metabolismo , Interleucina-8/biosíntesis , Interleucina-8/genética , Interleucina-8/metabolismo , FN-kappa B/biosíntesis , FN-kappa B/metabolismo , Donantes de Óxido Nítrico/farmacología , Regiones Promotoras Genéticas/inmunología , ARN Mensajero/biosíntesis , Rhinovirus/efectos de los fármacos , Sulfasalazina/farmacología , Factores de TiempoRESUMEN
OBJECTIVES: The purpose of this study was to determine long-term outcome in adults with congenitally corrected transposition of the great arteries (CCTGA), with particular emphasis on systemic ventricular dysfunction and congestive heart failure (CHF). BACKGROUND: Patients with CCTGA have the anatomical right ventricle as their systemic pumping chamber, with ventricular dysfunction and CHF being relatively common in older adults. METHODS: Retrospective analysis of records of 182 patients from 19 institutions were reviewed to determine current status and possible risk factors for systemic ventricular dysfunction and CHF. Factors considered included age, gender, associated cardiac defects, operative history, heart block, arrhythmias and tricuspid (i.e., systemic atrioventricular) regurgitation (TR). RESULTS: Both CHF and systemic ventricular dysfunction were common in groups with or without associated cardiac lesions. By age 45, 67% of patients with associated lesions had CHF, and 25% of patients without associated lesions had this complication. The rates of systemic ventricular dysfunction and CHF were higher with increasing age, the presence of significant associated cardiac lesions, history of arrhythmia, pacemaker implantation, prior surgery of any type, and particularly with tricuspid valvuloplasty or replacement. Aortic regurgitation (a previously unreported problem) was also relatively common in this patient population. CONCLUSIONS: Patients with CCTGA are increasingly subject to CHF with advancing age; this complication is extremely common by the fourth and fifth decades. Tricuspid (systemic atrioventricular) valvular regurgitation is strongly associated with RV (anatomical right ventricle connected to aorta in CCTGA patients; systemic ventricle in CCTGA) dysfunction and CHF; whether it is causative or a secondary complication remains speculative.
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Insuficiencia Cardíaca/etiología , Transposición de los Grandes Vasos/complicaciones , Disfunción Ventricular/etiología , Adulto , Factores de Edad , Ecocardiografía Doppler , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/fisiopatología , Humanos , Incidencia , Masculino , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Factores Sexuales , Transposición de los Grandes Vasos/diagnóstico por imagen , Transposición de los Grandes Vasos/fisiopatología , Disfunción Ventricular/epidemiología , Disfunción Ventricular/fisiopatologíaRESUMEN
OBJECTIVE: The aim of this study is to determine the level of clinical auscultation skills in pediatric residents at Duke University Medical Center. METHODS: Forty-seven residents from pediatrics and joint medicine/pediatrics training programs at Duke University Medical Center were enrolled in this study. They were asked to examine the cardiovascular patient simulator, Harvey, and report their findings. Five common conditions seen in the pediatric population were presented: ventricular septal defect, atrial septal defect, pulmonary valve stenosis, combined aortic valve stenosis and insufficiency, and innocent systolic ejection murmur. The responses were scored by the number of features and diagnoses accurately reported. Five pediatric cardiologists and cardiologists in training were also asked to participate in a manner similar to the trainees. RESULTS: The mean score of features identified for the resident group was 11.4 +/- 2.6 of a possible 19. The diagnostic accuracy was 33%. There was no significant difference between residents by year of training or by type of residency program, although there was a trend toward improved performance with more training. The difference in performance between the pediatric cardiology group and the residents group was striking. The condition that was most frequently misdiagnosed was the innocent systolic ejection murmur. CONCLUSIONS: The clinical auscultation skills of pediatric residents in this study were suboptimal. There was a trend toward improvement as training progressed, although not statistically significant. These skills are likely to improve further with increased exposure to patients with cardiovascular disease especially in the ambulatory care setting.
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Competencia Clínica , Auscultación Cardíaca , Cardiopatías/diagnóstico , Internado y Residencia , Pediatría/educación , Adulto , Insuficiencia de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/diagnóstico , Niño , Soplos Cardíacos/diagnóstico , Defectos del Tabique Interatrial/diagnóstico , Defectos del Tabique Interventricular/diagnóstico , Humanos , Estenosis de la Válvula Pulmonar/diagnósticoRESUMEN
Previous studies in isolated, ventilated lungs have demonstrated by indirect measurements that oxidant generation occurs during pulmonary ischemia before reperfusion. To identify and quantify the types of free radical species generated during ischemia, we used electron paramagnetic resonance (EPR) spectroscopy in the presence and absence of the spin trap, 5,5-dimethyl-1-pyrroline-N-oxide (DMPO). EPR spectra obtained from the vascular effluent of isolated ferret lungs, contained a doublet signal (g = 2.005) indicative of ascorbyl radical. This signal doubled in magnitude after 180 min of ischemia, providing evidence of oxidant formation during ischemia. When DMPO, which reacts with radicals including superoxide anions and hydroxyl radicals, was added to the perfusate, the spectra contained ascorbyl radical signals but no DMPO-adducts. To clarify the relationship between ascorbyl radical and DMPO-adduct formation, additional studies were conducted in the presence and absence of ascorbate with isolated lung mitochondria as the source of free radicals. The results showed that in the presence of ascorbate, oxygen free radicals were not detected by EPR spin trapping with DMPO because of the formation of prominent ascorbyl radical signals. These data suggest that DMPO may be useful for the detection of reactive oxygen species in isolated lungs, provided the ascorbate can be sufficiently depleted. Alternatively, as shown by our results, EPR studies that directly monitor ascorbyl radical formation may be used as a marker of oxidative stress in the lung.
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Isquemia/patología , Pulmón/irrigación sanguínea , Mitocondrias/patología , Especies Reactivas de Oxígeno/metabolismo , Animales , Ácido Ascórbico/metabolismo , Hurones , Radicales Libres , Pulmón/patología , Espectroscopía de Resonancia Magnética , Masculino , Estrés Oxidativo/fisiologíaRESUMEN
We evaluated the ability of real-time 3-dimensional (RT3D) echocardiography to diagnose congenital heart defects and its potential for presenting structural abnormalities in novel views. Seventy-five patients with suspected congenital heart defects were examined with the use of RT3D echocardiography. Images were reviewed off-line as multiple slices of the raw data or as volume-rendered images by a blinded observer. Diagnoses made from blinded review of the RT3D images were compared with the clinical report of the 2D echocardiogram obtained at the same visit. Real-time 3D echocardiography identified all structural abnormalities except for small atrial septal defects in 2 patients and coronary artery anatomy in D-transposition of the great arteries. Less than 5 minutes were needed to acquire RT3D images in all cases, and sedation was never required. Unique region-oriented views obtained from the 3D data set can be acquired quickly and have the potential to enhance understanding of complex cardiac anatomy.
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Ecocardiografía Tridimensional , Cardiopatías Congénitas/diagnóstico por imagen , Adolescente , Niño , Preescolar , Diagnóstico Diferencial , Humanos , Lactante , Recién Nacido , Variaciones Dependientes del Observador , Reproducibilidad de los Resultados , Grabación en VideoRESUMEN
BACKGROUND: Host defense system activation occurs with cardiopulmonary bypass (CPB) and is thought to contribute to the pathophysiological consequences of CPB. Complement inhibition effects on the post-CPB syndrome were tested with soluble complement receptor-1 (sCR1). METHODS AND RESULTS: Twenty neonatal pigs (weight 1.8 to 2.8 kg) were randomized to control and sCR1-treated groups. LV pressure and volume, left atrial pressure, pulmonary artery pressure and flow, and respiratory system compliance and resistance were measured. Preload recruitable stroke work, isovolumic diastolic relaxation time constant (tau), and pulmonary vascular resistance were determined. Pre-CPB measures were not statistically significantly different between the 2 groups. After CPB, preload recruitable stroke work was significantly higher in the sCR1 group (n=5, 46.8+/-3.2x10(3) vs n=6, 34.3+/-3.7x10(3) erg/cm(3), P=0.042); tau was significantly lower in the sCR1 group (26.4+/-1.5, 42.4+/-6. 6 ms, P=0.003); pulmonary vascular resistance was significantly lower in the sCR1 group (5860+/-1360 vs 12 170+/-1200 dyn. s/cm(5), P=0.009); arterial PO(2) in 100% FIO(2) was significantly higher in the sCR1 group (406+/-63 vs 148+/-33 mm Hg, P=0.01); lung compliance and airway resistance did not differ significantly. The post-CPB Hill coefficient of atrial myocardium was higher in the sCR1 group (2.88+/-0.29 vs 1.88+/-0.16, P=0.023). CONCLUSIONS: sCR1 meaningfully moderates the post-CPB syndrome, supporting the hypothesis that complement activation contributes to this syndrome.