A severe heparin-induced thrombocytopenia is reported in a child suffering from acute myocarditis. Thrombocytopenia (80.10(9)/l) occurred on day 5 (D5) of heparin therapy which was thus discontinued during 8 hours but reintroduced on the view of a negative platelet aggregation test using standard heparin. On D10, while thrombocytopenia persisted the presence of two intra-cardiac thrombi led to replace standard heparin by low molecular weight heparin (Fraxiparin), associated with vitamin K antagonist (phenindione). On D12, a 3rd intra-cardiac thrombus required immediate discontinuation of Fraxiparin therapy. Platelet aggregation tests performed on D14 were positive in the presence of standard heparin and of low molecular weight heparin, thus demonstrating the existence of thrombocytopenia induced by standard heparin and secondly by low molecular weight heparin. This observation led the authors to discuss the diagnosis and the therapeutic management of heparin-induced thrombocytopenia.
Propionibacterium acnes endocarditis is an uncommon infection in pediatrics. We describe a case of P. acnes endocarditis in a 16-year-old boy that occurred 6 months after recurrent surgery for a congenital cardiopathy. Molecular identification of P. acnes was obtained. He recovered from this infection after a surgical treatment and with a prolonged antibiotic regimen including ceftriaxone.
We report the early complications of stent implantation. Since 1/1/97 to 1/12/02, we implanted 91 stents in 76 patients. Median age and weight were 15 years (range 0.3-43) and 49 kg (range 3-96). Primary diagnosis were: pulmonary atresia with ventricular septal defect (n = 17), tetralogy of Fallot (n = 13), aortic coarctation (n = 15), transposition of the great arteries (n = 3), truncus arteriosus (n = 6), univentricular heart (n = 7), other anomalies (n = 28). Indications to stent implantation were: stenosis of the pulmonary outflow and/or pulmonary branches (n = 44), aortic recoarctation (n = 14), native aortic coarctation (n = 1), systemic venous channels obstruction (n = 14), other (n = 3). The stents were: Palmaz (n = 57), non premounted CP (n = 8), premounted CP (n = 3), Palmaz Corinthian (n = 19), self-expanding (n = 4). Procedural complications occurred in 24 patients (31%) and included: 11 balloon bursting, 8 stent slipping, 1 stent migration, 4 wall dissections. Five patients (21%) needed urgent surgery. Sixty three percent of complications occurred during pulmonary outflow or pulmonary branches stenting, 25% during stenting of the aortic arch, 12% during other procedures. All but 2 complications were observed with non premounted stents. In conclusion, the use of not premounted stents, although widely diffuse, has a not negligible incidence of complications, leading to longer procedures, to the use of a large variety of materials and needing more than occasionally a surgical solution. A larger use of premounted stents, when possible, is recommended.
Incessant reciprocating tachycardia (IRT) was diagnosed in 10 children aged 0-11 years (mean 2.5 years), followed-up for an average of 11 years (range 4-22 years). 8 children were treated for an average period of 2.8 years (range 0.5-6 years) with the association of amiodarone and digitoxine. All children were treated initially or secondarily with verapamil and/or betablockers with digitoxine for an average of 4.6 years (range 1-9 years). The true frequency of IRT, its tolerance and the age at diagnosis did not indicate the probable required length of treatment with amiodarone, but only the initial response to this drug. Finally, 5 patients were cured and in sinus rhythm, and the other 5 were well controlled, having only occasional bursts of tachycardia. When we compared one group of 5 cases with clinical signs of cardiac failure and radiological cardiomegaly (CTR greater than 0.60) with a second group of 5 cases in which the arrhythmia was better tolerated, surprisingly, the frequency of intreated IRT was not t he factor which influenced its tolerance (198/min vs 194/min). On the other hand, the following differences were observed between the two groups: a younger age at diagnosis in the first group (5 months vs 4.6 years) responsible for the longer follow-up period (14.5 vs 7 years), earlier treatment period with amiodarone (3.6 years compared to 5.5 years) and a longer treatment period with this drug (3.5 vs 2 years). It was only at about the age of 7 that this treatment could be withdrawn or changed with half the children completely cured, and the other half only controlled.(ABSTRACT TRUNCATED AT 250 WORDS)
BackgroundPulmonary artery banding is proposed as a first palliation in infants with complex congenital heart disease and high pulmonary blood flow. In addition, it may be used to retrain the left ventricle. Optimal tightening may be difficult to obtain, leading to reoperation. An implantable device for pulmonary artery banding with telemetric control was recently developed allowing for repeated adjustments, but it is presently limited to patients weighing less than 20 kg. In large animals, we tested an off-label adjustable gastric banding system for pulmonary artery banding.Methods and ResultsFourteen ewes weighing 50 to 75 kg underwent implantation of the Lap-Band device (BioEnterics Corp, Santa Barbara, Calif) around the main pulmonary artery through a left thoracotomy. All had functional evaluation with progressive occlusion and opening of the device at implantation and every 2 weeks until sacrifice immediately after implantation (group 1, n = 8), at 1 month (group 2, n = 3), at 3 months (group 3, n = 3), or death. Invasive pressure measurements in the right ventricle and aorta were carried out each time. Devices were easily implanted in all animals. Progressive occlusion and reopening were possible in all animals during each time point. Two animals died of right heart failure related to excessive tightening of the band. Retrieval of the device without any major damage was possible in 12 of 14 animals.ConclusionWith this implantable device, we were able to adjust the pulmonary artery diameter in animals. Patients requiring left ventricle retraining and weighing more than 30 kg would benefit from the device’s use in humans. Pulmonary artery banding is proposed as a first palliation in infants with complex congenital heart disease and high pulmonary blood flow. In addition, it may be used to retrain the left ventricle. Optimal tightening may be difficult to obtain, leading to reoperation. An implantable device for pulmonary artery banding with telemetric control was recently developed allowing for repeated adjustments, but it is presently limited to patients weighing less than 20 kg. In large animals, we tested an off-label adjustable gastric banding system for pulmonary artery banding. Fourteen ewes weighing 50 to 75 kg underwent implantation of the Lap-Band device (BioEnterics Corp, Santa Barbara, Calif) around the main pulmonary artery through a left thoracotomy. All had functional evaluation with progressive occlusion and opening of the device at implantation and every 2 weeks until sacrifice immediately after implantation (group 1, n = 8), at 1 month (group 2, n = 3), at 3 months (group 3, n = 3), or death. Invasive pressure measurements in the right ventricle and aorta were carried out each time. Devices were easily implanted in all animals. Progressive occlusion and reopening were possible in all animals during each time point. Two animals died of right heart failure related to excessive tightening of the band. Retrieval of the device without any major damage was possible in 12 of 14 animals. With this implantable device, we were able to adjust the pulmonary artery diameter in animals. Patients requiring left ventricle retraining and weighing more than 30 kg would benefit from the device’s use in humans.
most paediatric cardiologists think that the optimal treatment for patients with functionally single ventricle is the relatively early construction, at from 2 to 7 years of age, of the total cavo-pulmonary circulation. this approach is based on the desire to produce an acyanotic child, such an outcome fostering the belief that the patient is cured. when using this therapeutic approach, the total connection is usually preceded by earlier creation of a partial connection, achieved by creating a bi-directional anastomosis between the superior caval vein and the right pulmonary artery at the age of from 3 to 9 months, without providing additional flow of blood to the lungs. this leads to severe cyanosis by the age of 3 years, when the flow increases in the inferior caval vein, and is the signal for early completion of the total connection. in this policy, the absence of additional flow to the lungs is justified by the fear of altering the ventricular function essential for the success of the total connection, because of the volume, and eventually the pressure, overload of the additional flow on the functionally single ventricle,which may impair its compliance and/or contractility, or be responsible for atrioventricular valvar regurgitation. these alterations in myocardial functions would then contraindicate, or increase, the mortality and morbidity of the total connection, producing deterioration in its long-term results.
