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Resumen La metahemoglobinemia ocasionalmente causa cianosis, particularmente cuando es congénita. Debido a sus vías enzimáticas deficientes y a la disminución de la capacidad de transporte de oxígeno, para los pacientes con metahemoglobinemia congénita es importante evitar la exposición a agentes oxidantes. A continuación, presentamos un paciente pediátrico con metahemoglobinemia congénita no diagnosticada preoperatoriamente que fue sometido a cateterismo con diagnóstico probable de hipertensión pulmonar bajo anestesia general. El paciente pediátrico era un niño de 10 años que presentaba una lectura de oximetría de pulso (SpO2) 92% antes de la inducción de la anestesia. La metahemoglobinemia se sospechó intraoperatoriamente por primera vez debido a un desajuste de la SpO2 de la oximetría de pulso digital y la SaO2 (saturación arterial de oxígeno), y luego se confirmó mediante múltiples longitudes de onda con la CO-oximetría. Se discuten la fisiopatología, etiología, manifestaciones clínicas, consideraciones anestésicas y opciones de tratamiento de la metahemoglobinemia.

Abstract Methemoglobinemia occasionally causes cyanosis particularly in congenital methemoglobinemia. Avoidance of exposure to oxidizing agents is important for patients with congenital methemoglobinemia because of their deficient enzymatic pathways and decreased oxygen-carrying capacity. Here, we present a pediatric patient with preoperatively undiagnosed congenital methemoglobinemia who underwent catheterization with probably diagnosis of pulmonar hypertension under general anesthesia. The pediatric patient was a 10-year-old who displayed a low pulse oximetry reading of 92% prior to induction of anesthesia. Methemoglobinemia was first suspected intraoperatively because of a mismatch of SpO2 of finger pulse oximetry and SaO2 of arterial blood, and was later confirmed by multiplewavelength CO-oximetry. The pathophysiology, etiology, clinical manifestations, anesthetic considerations, and treatment options of methemoglobinemia are discussed.

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Resumen La hemoglobina M es un desorden hereditario infrecuente, causante de metahemoglobinemia y, por ende, cianosis. Las manifestaciones clínicas de esta enfermedad son amplias y variadas, por lo que se debe considerar como diagnóstico diferencial en un recién nacido con cianosis sin otra causa aparente. A continuación, se presenta el caso de un recién nacido de 5 horas de vida con cianosis generalizada desde el nacimiento y con saturaciones de oxígeno de entre 60-70%, en el que se descartaron patologías como hipoxia perinatal, patología pulmonar o cardíaca y sepsis y se documentó un nivel de metahemoglobina elevado, reportado en 21,6%, con lo cual se estableció el diagnóstico de metahemoglobinemia. El tratamiento administrado fueron dos dosis de azul de metileno, pero no hubo respuesta clínica. Por este motivo, se realizó electroforesis de hemoglobina, la cual fue compatible con hemoglobina M (Iwate o Kankakee), lo que se confirma su causa congénita de metahemoglobinemia.

Abstract Hemoglobin M is a rare hereditary disorder that causes ethemoglobinemia and therefore cyanosis. The clinical manifestations of this condition differs considerably, so it should be considered as a differential diagnosis in a newborn with cyanosis, with no other apparent cause. The case of a 5 hours old newborn is presented below, with generalized cyanosis from birth with oxygen saturations between 60-70%, in whom, upon ruling out pathologies such as perinatal hypoxia, pulmonary disease, heart disease and sepsis, a high level of methemoglobin is documented, reported in 21,6%; the diagnosis of methemoglobinemia was established. The treatment administered was two doses of methylene blue with no response. For this reason, hemoglobin electrophoresis was performed, which was compatible with Hemoglobin M (Iwate or Kankakee), confirming its congenital cause.

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CLINICAL DATA: Infant, nine months of age, female, diagnosed with congenital heart disease, with signs of heart failure associated with cyanosis and difficulty in gaining weight. CHEST RADIOGRAPHY: Cardiomegaly with prevalence of pulmonary vascular network. ELECTROCARDIOGRAM: Ectopic atrial rhythm with right ventricular overload and left anterosuperior divisional block. ECHOCARDIOGRAM: Single atrium with absent interatrial septum, atrioventricular connection with a single valve and two orifices, with increased pulmonary pressure and high Qp/Qs. COMPUTED TOMOGRAPHY: Absence of portal vein and intrahepatic segment of the inferior vena cava. Infrahepatic portion continuing with the azygos system at the level of the thoracic cavity, presence of mesenteric-caval communication associated with signs suggestive of hepatic peribiliary fibrosis. DIAGNOSIS: Abernethy malformation is a rare condition and represents an extrahepatic portosystemic shunt that develops between the mesenteric-portal vasculature and the systemic veins. It may be associated with cardiac malformations and advance with pulmonary hypertension and even the need for liver transplantation. Persistent cyanosis after corrective surgery led to a deeper investigation and correct diagnosis of this malformation. OPERATION: Sternotomy with 68 minutes of cardiopulmonary bypass and nine minutes of total circulatory arrest. In the postoperative period, persistence of cyanosis was evident, even though there were no immediate complications. Patient was discharged on the 10th postoperative day. An abdominal computed tomography angiography confirmed the diagnosis of Abernethy type I malformation, and the patient was transferred for liver transplantation after congenital heart disease treatment.

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ABSTRACT Clinical data: Infant, nine months of age, female, diagnosed with congenital heart disease, with signs of heart failure associated with cyanosis and difficulty in gaining weight. Chest radiography: Cardiomegaly with prevalence of pulmonary vascular network. Electrocardiogram: Ectopic atrial rhythm with right ventricular overload and left anterosuperior divisional block. Echocardiogram: Single atrium with absent interatrial septum, atrioventricular connection with a single valve and two orifices, with increased pulmonary pressure and high Qp/Qs. Computed tomography: Absence of portal vein and intrahepatic segment of the inferior vena cava. Infrahepatic portion continuing with the azygos system at the level of the thoracic cavity, presence of mesenteric-caval communication associated with signs suggestive of hepatic peribiliary fibrosis. Diagnosis: Abernethy malformation is a rare condition and represents an extrahepatic portosystemic shunt that develops between the mesenteric-portal vasculature and the systemic veins. It may be associated with cardiac malformations and advance with pulmonary hypertension and even the need for liver transplantation. Persistent cyanosis after corrective surgery led to a deeper investigation and correct diagnosis of this malformation. Operation: Sternotomy with 68 minutes of cardiopulmonary bypass and nine minutes of total circulatory arrest. In the postoperative period, persistence of cyanosis was evident, even though there were no immediate complications. Patient was discharged on the 10th postoperative day. An abdominal computed tomography angiography confirmed the diagnosis of Abernethy type I malformation, and the patient was transferred for liver transplantation after congenital heart disease treatment.

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Objectives: The aim of this study was to evaluate neurodevelopmental outcomes (motor development, nonverbal intelligence, and attention) in children with cyanotic congenital heart disease (CHD) compared with healthy children from a public hospital in southern Brazil. Materials and Methods: This was a cross-sectional study with pediatric patients of both sexes: 37 children with cyanotic CHD and a control group with 38 healthy children. Parents/guardians undertook a questionnaire and the SNAP IV scale (to evaluate attention) was applied. Two instruments were applied to each child: the R-2 Non-Verbal Intelligence test and the motor development scale. To assess the factors associated with insufficient performance in the three fields of neurodevelopment, a Poisson regression analysis was performed with a robust estimate. Results: There were no significant differences between children with cyanotic CHD and the control group for any of the neurodevelopmental outcomes studied. Low socioeconomic class was a factor associated with worse performance on the intelligence test and inattention. Furthermore, age was a factor for performance on the intelligence test, while a greater number of siblings was a factor associated with worse performance on the attention test. Conclusions: Public policies regarding child health must involve prioritizing the improvement of families' social conditions.

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Sulfhemoglobin (SulfHb) is formed by hemoglobin (Hb) oxidation by sulfur compounds. Sulfhemoglobinemia is mainly associated with drugs or intestinal bacterial overgrowth. Patients present with central cyanosis, an abnormal pulse oximetry and normal arterial oxygen partial pressure. These features are shared with methemoglobinemia (MetHb) whose diagnosis requires an arterial co-oximetry. Depending on the device used, SulfHb may produce interference with this technique. We report two females aged 31 and 43 years, consulting at the emergency room with cyanosis. Both had a history of acute and chronic, high dose zopiclone ingestion. Pulse oximetry showed desaturation but with normal arterial oxygen partial pressure. Cardiac and pulmonary diseases were ruled out. Co-oximetry in two different analyzers showed interference or normal MetHb percentages. No other complications ensued, and cyanosis decreased over days. Since MetHb was discarded among other causes of cyanosis in a compatible clinical context, the diagnosis of sulfhemoglobinemia was made. The confirmatory method is not available in Chile. The presence of SulfHb is difficult to diagnose, confirmatory tests are not readily available, and it frequently interferes with arterial co-oximetry. This is attributed to a similar absorbance peak of both pigments in arterial blood. Venous co-oximetry can be useful in this context. SulfHb is a self-limited condition in most cases, however it must be differentiated from methemoglobinemia to avoid inappropriate treatments like methylene blue.

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Introducción: La anomalía de Ebstein es una rara malformación con presentación sintomática respiratoria leve a grave a causa de defectos cardiacos congénitos manifestados durante la niñez. Objetivo: Exponer el caso en el cual el diagnóstico oportuno de esta enfermedad permitió el tratamiento integral del paciente. Presentación del caso: Recién nacido a término, quien a las siete horas de su nacimiento presentó saturación de oxígeno disminuida, examen físico sin cianosis, soplo pansistólico en la auscultación y cardiomegalia detectada por rayos X de tórax. Se realizó ecocardiograma que permitió diagnosticar al bebé como portador de la enfermedad de Ebstein con manifestaciones leves. Una vez que tiene mejoría clínica, se le proporcionó el alta médica con indicación de valoración por cardiología pediátrica. Conclusiones: La anomalía de Ebstein puede comenzar en el período neonatal con sintomatología de severidad variable. La sospecha clínica permite la confirmación diagnóstica y el seguimiento estrecho, sobre todo en casos severos(AU)

Introduction: Ebstein's anomaly is a rare malformation with mild to severe respiratory symptomatic presentation due to congenital heart defects manifested during childhood. Objective: To present the case in which the timely diagnosis of this disease allowed the comprehensive treatment of the patient. Case presentation: Full-term newborn, who at seven hours of birth presented decreased oxygen saturation, physical examination without cyanosis, pansystolic murmur in auscultation and cardiomegaly detected by chest X-rays. An echocardiogram was performed to diagnose the baby as a carrier of Ebstein's disease with mild manifestations. Once he had clinical improvement, he was discharged with an indication for assessment by pediatric cardiology. Conclusions: Ebstein's anomaly may begin in the neonatal period with symptoms of variable severity. Clinical suspicion allows for diagnostic confirmation and close follow-up, especially in severe cases(AU)

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Introducción: La metahemoglobina es una forma de hemoglobina en la que el grupo hemo, usualmente en forma ferrosa, es oxidado a forma férrica, lo que afecta el transporte de oxígeno. El incremento por encima de los valores de referencia se denomina metahemoglobinemia. Objetivo: Actualizar conceptos como prevención, manifestaciones clínicas, diagnóstico de laboratorio y tratamiento de elección de esta enfermedad, con la información disponible de la última década. Métodos: Se realizó una revisión de la literatura en inglés y español, a través del sitio web PubMed, el motor de búsqueda Google académico y Scielo, de artículos publicados en los últimos 10 años. Los términos de búsqueda usados incluyeron metahemoglobinemia, déficit de citocromo b5 reductasa, cianosis y cooximetría. Análisis y síntesis de la información: La metahemoglobinemia se puede clasificar en congénita y adquirida, esta última es la más frecuente. Es importante el diagnóstico de esta enfermedad que aunque es un padecimiento poco común, puede cursar con complicaciones graves e incluso la muerte. Puede ser evitable con diagnóstico temprano y tratamiento oportuno para reducir las complicaciones asociadas a este cuadro. Conclusiones: El diagnóstico y el tratamiento, profiláctico y terapéutico de la metahemoglobinemia en su etapa aguda o de mantenimiento, requieren la adecuada actualización del profesional de la salud(AU)

Introduction: Methemoglobin is a form of hemoglobin in which the heme group, usually in the ferrous form, is oxidized to the ferric form, which affects oxygen transport. The increase above the reference values ​​is called methemoglobinemia. Objective: To update concepts such as prevention, clinical manifestations, laboratory diagnosis and treatment of choice for this disease, with the information available from the last decade. Methods: A review of the literature in English and Spanish was carried out, through the PubMed website, the academic Google search engine and Scielo database, of articles published in the last 10 years. Search terms used included methemoglobinemia, cytochrome b5 reductase deficiency, cyanosis, and co-oximetry. Analysis and synthesis of information: Methemoglobinemia can be classified into congenital and acquired, the latter being the most common. It is important to diagnose this disease, which, although it is a rare condition, can cause serious complications, and even death, which are avoidable with early diagnosis and timely treatment that reduce the complications associated with this condition. Conclusions: The diagnosis and treatment, prophylactic and therapeutic, of methemoglobinemia, in its acute or maintenance stage, require adequate updating of the health professional(AU)

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Background: In cats, arterial thromboembolism is one of the most devastating diseases, with an acute presentation, andis often caused by undiagnosed cardiomyopathy. Defined as the obstruction of one or more arterial lumens by emboli,the arterial thromboembolism is responsible for hypoperfusion signs. As the temperature of the skin surface is directlyrelated to tissue perfusion, thermography can be promising for the early diagnosis of thromboembolism. Therefore, thisstudy reports the importance of thermography as a complementary examination for the diagnosis of thromboembolism inthe abdominal aorta of a domestic cat.Case: A 4-year-old mixed-breed cat weighing 2.95 kg was presented with a history of sudden onset paraplegia, apathy,and pain when handled, with greater intensity in the sacro-coccidian region. During physical exam, it was noted that thefemoral artery pulse was undetectable bilaterally during manual pulse measurement. Superficial and deep sensitivity inthe pelvic limbs and proprioception were also absent and the plantar cushions and nail beds of the posterior limbs werepale to cyanotic. Thermographic images revealed that the temperature of both hind limbs was lower than that of forelimbs,with difference of 3.2ºC and 2.9ºC between the left and right limbs, respectively. Doppler ultrasonography revealed theabsence of pulse and flow in the femoral arteries bilaterally. Electrocardiography revealed sinus tachycardia, with a heartrate of 250 bpm. Echocardiography revealed dilation of the left atrium and concentric cardiac hypertrophy. After 24 h, dueto the worsening of the clinical condition and unfavorable prognosis, the animal was euthanized and sent for necropsy.Necropsy revealed that the arterial lumen of the caudal abdominal aorta and bifurcation of the iliac arteries were obliterated...(AU)

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Abstract Clinical data: Patient diagnosed with common arterial trunk, submitted to pulmonary artery banding in another center and lost to clinical follow-up. Referred to our center at four years old, extremely cyanotic. Chest radiography: Cardiomegaly; attenuated peripheral vascular markings. Electrocardiography: Right ventricular hypertrophy. Echocardiography: Common arterial trunk, but it was not possible to analyze all the structures. Computed tomography angiography: Van Praagh type A4 common arterial trunk. Extremely hypoplastic right and left pulmonary arteries. Diagnosis: Association of aortic arch interruption type A is uncommon and should be considered. Operation: Debanding of pulmonary arteries allowing for possible future complete repair.

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CLINICAL DATA: Patient diagnosed with common arterial trunk, submitted to pulmonary artery banding in another center and lost to clinical follow-up. Referred to our center at four years old, extremely cyanotic. Chest radiography: Cardiomegaly; attenuated peripheral vascular markings. Electrocardiography: Right ventricular hypertrophy. Echocardiography: Common arterial trunk, but it was not possible to analyze all the structures. Computed tomography angiography: Van Praagh type A4 common arterial trunk. Extremely hypoplastic right and left pulmonary arteries. DIAGNOSIS: Association of aortic arch interruption type A is uncommon and should be considered. OPERATION: Debanding of pulmonary arteries allowing for possible future complete repair.

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Background: In cats, arterial thromboembolism is one of the most devastating diseases, with an acute presentation, andis often caused by undiagnosed cardiomyopathy. Defined as the obstruction of one or more arterial lumens by emboli,the arterial thromboembolism is responsible for hypoperfusion signs. As the temperature of the skin surface is directlyrelated to tissue perfusion, thermography can be promising for the early diagnosis of thromboembolism. Therefore, thisstudy reports the importance of thermography as a complementary examination for the diagnosis of thromboembolism inthe abdominal aorta of a domestic cat.Case: A 4-year-old mixed-breed cat weighing 2.95 kg was presented with a history of sudden onset paraplegia, apathy,and pain when handled, with greater intensity in the sacro-coccidian region. During physical exam, it was noted that thefemoral artery pulse was undetectable bilaterally during manual pulse measurement. Superficial and deep sensitivity inthe pelvic limbs and proprioception were also absent and the plantar cushions and nail beds of the posterior limbs werepale to cyanotic. Thermographic images revealed that the temperature of both hind limbs was lower than that of forelimbs,with difference of 3.2ºC and 2.9ºC between the left and right limbs, respectively. Doppler ultrasonography revealed theabsence of pulse and flow in the femoral arteries bilaterally. Electrocardiography revealed sinus tachycardia, with a heartrate of 250 bpm. Echocardiography revealed dilation of the left atrium and concentric cardiac hypertrophy. After 24 h, dueto the worsening of the clinical condition and unfavorable prognosis, the animal was euthanized and sent for necropsy.Necropsy revealed that the arterial lumen of the caudal abdominal aorta and bifurcation of the iliac arteries were obliterated...

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Resumen La enfermedad oclusiva aorto-ilíaca, denominada también como Síndrome de Leriche, es la oclusión de la aorta abdominal en su segmento infrarrenal, siendo la aterosclerosis la causa principal. Los factores de riesgo más frecuentes, son: la hipertensión, la diabetes mellitus, la dislipidemia y el tabaquismo. Se describe el caso de un paciente con factores de riesgo para enfermedad ateroesclerótica quien ingresó por dolor en miembros inferiores, claudicación intermitente, cambios de coloración en pie y ausencia de pulsos en miembros inferiores. Clínicamente, esta entidad se caracteriza por la tríada clásica: Claudicación, disfunción eréctil y pulsos distales disminuidos. Debido a su cronicidad, muchos suelen ser asintomáticos debido a la circulación colateral que desarrollan, lo que conlleva a un subregistro. Los estudios vasculares como: la ecografía doppler, la angiotomografía computarizada y la angiografía aórtica pueden ayudar a confirmar el diagnóstico y la ubicación de la estenosis, siempre teniendo como pilar fundamental la sospecha clínica.

Abstract Aortoiliac occlusive disease, also known as Leriche´s Syndrome, is the occlusion of the abdominal aorta in its infrarenal segment, with atherosclerosis being the main cause. The most frequent risk factors are: hypertension, diabetes mellitus, dyslipidemia and smoking. The case of a patient with risk factors for atherosclerotic disease who was admitted due to pain in the lower limbs, intermittent claudication, discoloration of the foot and absence of pulses in the lower limbs is described. Clinically, is characterized by the classic triad: Claudication, erectile dysfunction and decreased distal pulses. Due to their chronicity, many are usually asymptomatic due to the collateral circulation they develop, which leads to underreporting. Vascular studies such as: Doppler ultrasound, computed tomography angiography and aortic angiography can help confirm the diagnosis and location of stenosis, always having clinical suspicion as a fundamental pillar.

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Abstract Pulmonary venous connections may be infrequently abnormal in patients with tetralogy of Fallot (TOF). A special subgroup of partial anomalous pulmonary venous return,"scimitar cyndrome", and its coexistence with TOF is less frequently reported. It may proceed unnoticed, as cyanosis already predominates in the clinical picture. This uncommon association must be kept in mind for patients with TOF who have an accessory flow in the inferior vena cava, especially when all pulmonary venous return to the left atrium is not clearly seen.

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Resumo Fundamento A fístula da artéria coronária (FAC) é uma conexão direta entre uma ou mais artérias coronárias e câmaras cardíacas ou um grande vaso; pode estar associada à cardiopatia congênita. Objetivo Estabelecer os padrões de trajetos de FAC a partir de dados ecocardiográficos e correlacioná-los com aspectos clínicos e cardiopatias congênitas. Métodos Um total de 7.183 prontuários médicos de crianças menores de 5 anos de idade com cardiopatia submetidas a ecodopplercardiograma colorido foram analisados utilizando o teste de correlação de Spearman para associar sinais, sintomas e cardiopatia à FAC, com nível de significância de 5%. Resultados Vinte e seis crianças (0,0036%) apresentaram FAC, nos seguintes trajetos: da artéria coronária direita para o ventrículo direito (26,92%), da artéria coronária esquerda para o ventrículo direito (23,08%), do ramo interventricular anterior para o ventrículo direito (23,08%), da artéria coronária direita para o átrio direito (11,54%), da artéria coronária esquerda para o tronco pulmonar (7,69%) e do ramo interventricular anterior para o tronco pulmonar (7,69%). Em 57,69% dos pacientes, houve uma correlação positiva entre sintomas e a FAC (p = 0,445), relacionada à dispneia ou cianose (53,84%). Em 96,15%, a cardiopatia congênita estava associada à FAC; principalmente, a comunicação interventricular e a comunicação interatrial, em 34,62% dos casos, correlacionaram-se positivamente com a FAC (p = 0,295). O trajeto da FAC foi representado em três dimensões pelo software de modelagem, texturização e animação Cinema 4D R19. Conclusão A FAC é uma entidade anatômica incomum que apresenta quadro clínico compatível com dispneia e cianose e está associada a cardiopatias congênitas, principalmente com a CIV ou a CIA. De acordo com as análises ecocardiográficas, as fístulas na ACD, na ACE ou no RIVA representam aproximadamente um terço dos pacientes, com trajeto prioritário para as câmaras cardíacas direitas.

Abstract Background Coronary artery fistula (CAF) is a direct connection of one or more coronary arteries to cardiac chambers or a large vessel; it may be associated with congenital heart disease. Objective To establish CAF pathway patterns from echocardiographic data and to correlate them with clinical aspects and congenital heart disease. Methods A total of 7.183 medical records of children under the age of five years with cardiac disease submitted to color Doppler echocardiography and Spearman's Correlation test were used to associate signs and symptoms and cardiopathy to CAF with a significance level of 5%. Results Twenty six children (0.0036%) presented CAF: from the right coronary artery (RCA) to the right ventricle (RV) 26.92%, from the left coronary artery (LCA) to the RV 23.08%, from the anterior interventricular branch (AIVB) to RV 23.08%, RCA to right atrium (RA) 11.54%, LCA for pulmonary trunk (PT) 7.69% or AIVB for PT 7.69%. In 57.69% of the patients, there was a positively correlated symptomatology to CAF with p=0.445 related to dyspnea or cyanosis (53.84%); in 96.15%, congenital heart disease associated with CAF, mainly interventricular communication (IVC) or interatrial communication (IAC) in 34.62% positively correlated to CAF with p=0.295. CAF pathway was represented in three dimensions by software modeling, texturing and animation Cinema 4D R19. Conclusion CAF is an uncommon anatomical entity that presents a clinical picture compatible with dyspnea and cyanosis, and this is associated with congenital heart disease, mainly with IVC or IAC. According to echocardiographic analyzes, fistulas in RCA, LCA, or AIVB represent about one-third of the patients, with a priority pathway for right heart chambers.

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OBJECTIVE: To assess whether children with symptomatic congenital heart defects (CHDs) at birth (cyanosis and/or heart failure) are at greater risk of adverse neurodevelopmental outcomes at 8 years of age. STUDY DESIGN: From a prospective population-based cohort study of newborns with CHDs (EPICARD), we included 473 children with available neurodevelopmental assessments at 8 years of age. We grouped the CHD based on symptoms at birth and need for early neonatal intervention. Ventricular septal defects that closed spontaneously within the first year of life were considered the control group. Neurodevelopmental outcomes were assessed using the Kauffman Assessment Battery Test for Children, Second Edition, for IQ (mean 100 ± 15), and the Developmental NEuroPSYchological Assessment Battery, Second Edition, for detailed assessment of specific neurocognitive domains (mean 10 ± 3). Multivariable regression analysis was used to compare the outcomes across the CHD groups after considering potentially confounding variables. RESULTS: Compared with the control group, children with cyanotic CHD without heart failure had lower scores for IQ, -7.2 (95% CI -13.4 to -1.2). Children with noncyanotic CHD with heart failure had lower scores in the specific domains of language -1.5 (95% CI -2.2 to -0.7), and memory and learning -1.3 (95% CI -2.4; -0.3). Those with both cyanotic CHD and heart failure had lower scores for IQ, -7.6 (95% CI -13.5 to -1.8), as well as the specific domains of language and memory and learning, -2.0 (95% CI -2.9 to -1.0) and -1.1 (95% CI -2.3 to -0.1), respectively. CONCLUSIONS: Children with symptomatic CHD at birth are at greater risk of adverse neurodevelopmental outcomes at 8 years of age, with the greatest risk for those who were born with both cyanosis and heart failure.

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Pulmonary venous connections may be infrequently abnormal in patients with tetralogy of Fallot (TOF). A special subgroup of partial anomalous pulmonary venous return,"scimitar cyndrome", and its coexistence with TOF is less frequently reported. It may proceed unnoticed, as cyanosis already predominates in the clinical picture. This uncommon association must be kept in mind for patients with TOF who have an accessory flow in the inferior vena cava, especially when all pulmonary venous return to the left atrium is not clearly seen.

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Background: Acute dyspnea is a clinical emergency with a presentation similar to several etiologies. Cats are usually referred with complaints of anorexia, abdominal breathing, cyanosis, and open mouth breathing, and veterinarians should stabilize the animals as soon as possible. The incidence of aspiration of foreign bodies is low, particularly in this species. The diagnosis consists of observing the foreign structure in the lumen of the trachea, commonly performed using radiography or bronchoscopy. This report describes a case of a feline with a tracheal foreign body, with a detailed description of the clinical findings and successful treatment. Case: A 10-year-old female feline exhibited severe dyspnea and cyanosis. During the anamnesis, the owner stated that the clinical signs suddenly presented one day prior, after the animal ingested a piece of fish. Physical examination revealed changes in pulmonary auscultation, which was bilaterally muffled, and intense respiratory distress, as observed by the evident signs of exhaustion (sternal decubitus, reduced muscle tone), in addition to cyanotic mucous membranes. The animal was intubated and maintained under anesthesia with propofol infusion and respiratory support (ambu) for 1 h, during which complementary examinations were performed. Chest radiography showed the presence of a radiopaque structure (approximately 0.5 cm) in the tracheal region. Thus, we decided to remove the structure using bronchoscopy. The foreign body was located above the main bronchial bifurcation and was removed. There was an improvement in oxygenation after 20 min of maintenance of ventilatory support, followed by weaning of the animal's successful respiratory support. Antibiotic therapy and analgesia were prescribed at home, and the animal exhibited full recovery after 10 days. Discussion: Dyspnea is a clinical sign that should be treated as an emergency, as it is associated with high mortality. In these cases, positive pressure ventilation is indicated in three situations: persistent hypoventilation, severe hypoxemia unresponsive to oxygen therapy, and excessive respiratory effort or fatigue. Dyspnea may be due to impairment of the upper or lower airway or restrictive conditions. Clinically, felines with tracheal foreign bodies have a sudden onset of dyspnea, tachypnea, cough, and lethargy. In these patients, the reduction in lung sounds is a common finding, as observed in the present case. The occurrence of tracheal foreign bodies in cats is rare and, depending on the type of foreign body and its location in the airway, complete obstruction of the respiratory tract may occur. In the present case, it was possible to observe the foreign body in the trachea on radiographic images. Felines with tracheal foreign bodies generally present a structure located close to the carina, as observed in the present case. Bronchoscopy using a flexible or rigid tube is considered the gold-standard technique for removing foreign bodies from the respiratory tract, and the greatest difficulty during the removal procedure is ensuring that the airways are not obstructed by the instruments used. The use of these materials is not free of complications, as they may be responsible for the development of pneumothorax, pneumomediastinum, dyspnea, and respiratory failure. In the present case, there were no complications during or after the procedure, and the patient recovered completely.(AU)

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