Biomedical subjects
Publications and source records attributed to R Fogelman.
Fluoxetine is an antidepressant drug, only recently discovered to be a QT interval prolonging agent. The first case is presented of an infant of a mother treated with fluoxetine during pregnancy who had a transiently prolonged QTc interval, concluded to be drug induced. Clinical and electrocardiographic monitoring of newborns of antidepressant treated mothers is needed.
We have had experience of an 18-month-old boy with a cardiomyopathy who died a few minutes after removal of his cast with a saw, apparently from a malignant cardiac arrhythmia triggered by anxiety. We therefore examined the anxiety reaction to this method of removal of a plaster cast in 20 healthy children; ten were provided with hearing protectors and ten were not. The level of anxiety was assessed by measuring the heart rate, a known physiological indicator of anxiety, before, during and five minutes after removal of the cast. The noise level was also measured. The results showed a mean increase in heart rate during the procedure of 27.9 beats per minute (bpm) (26.9%) in the children with no hearing protectors and 10.4 bpm (11.1%) in children who used hearing protectors (p < 0.001). Five minutes after the procedure the heart rate had returned to the baseline rate in all patients. We recommend that hearing protectors should be used in children undergoing removal of a plaster cast to decrease the anxiety reaction. If possible, clinicians should avoid the use of a saw for this purpose in children with a cardiomyopathy.
The acute complications of therapeutic cardiac catheterization for congenital heart disease as performed currently in a small unit were reviewed. In recent years, there has been a significant increase in the number of lesions thought amenable to catheter therapy. Only a few reports, however, have addressed the overall incidence of acute complications of therapeutic cardiac catheterization, all representing the experience of centres performing moderate-to-large numbers of procedures. A retrospective review was performed of 425 therapeutic catheter procedures performed at our institution between May 1993 and November 1997. Acute complications were retrieved from the database. This included all adverse events that were clinically recognized at the time of or within 2 weeks after the procedure and which, to the best of the authors' clinical judgement, were related to the catheterization and not part of the natural history of the child's illness. All patients were observed overnight following the procedure, and stayed in hospital if a complication developed. There were 49 acute complications (11.5%), of which 43 (10.1%) were deemed minor and 6 (1.4%) were considered major. The rate was low in patients with valvar pulmonary stenosis, including three neonates (3/45, 6.7%), for those undergoing angioplasty of native co-arctation (1/15, 6.7%) and pulmonary arteries (2/27, 7.4%); and for coil embolization of systemic to pulmonary collateral arteries (1/16, 6.3%). The rate was high in patients with valvar aortic stenosis, including 12 neonates (9/37, 24.3%), and for angioplasty of re-coarctation (4/23, 21.7%). There were more overall complications in neonates (25.6%) than in older patients (10.1%) (p < 0.01). Two patients died (0.5%), but no patient required emergency surgical intervention. In spite of the introduction of many new therapeutic modalities with greater intrinsic risk, and the fact that patients with more complex lesions and who are more acutely ill are being treated, the overall rate of complications remains relatively low. This probably reflects improvements in pericatheterization medical management, in selection of patients, in procedural techniques, and in the experience of operators.
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OBJECTIVES: Life-threatening arrhythmias and prolonged QT interval have been reported in adults and children using cisapride, a medication structurally similar to procainamide. Premature infants have reduced activity of cytochrome p-450, the system responsible for metabolism of cisapride, which could lead to QT prolongation. Therefore, we prospectively studied premature infants and children receiving cisapride to analyze the effect of prolonged cisapride therapy on QT interval. DESIGN: Premature infants in a neonatal intensive care unit and children seen at a pediatric gastroenterology clinic in a tertiary care hospital had electrocardiography-analyzed and -corrected QT interval measured before cisapride (0.8/mg/kg per day) therapy, and again after 1 month of therapy. If baseline electrocardiography was not performed initially, it was obtained after cessation of therapy. RESULTS: A total of 30 children participated in the study. Mean corrected QT interval was similar at baseline and at 1 month after therapy. Significant QT prolongation was not found, and no adverse effects were recorded. CONCLUSIONS: Corrected QT interval during prolonged cisapride therapy at 0.8 mg/kg per day appears to be similar for premature infants and children. An inherent trend toward QT prolongation was not detected in either group. In the absence of other risk factors that alter cisapride metabolism or predispose to arrhythmia, cisapride may be safe for use in premature infants as well as in children. Additional studies are needed to confirm these data.
Isolated secundum atrial septal defect is one of the most common congenital heart defects. Surgical closure is the treatment of choice but is associated with a chest scar, some morbidity and a relatively long recovery and the use of cardiopulmonary bypass. Transcatheter closure of secundum atrial septal defect is therefore an attractive approach. 3 children, aged 5-10 years, underwent successful transcatheter closure of moderate to large central atrial septal defects with the Cardioseal device. The procedures were performed under x-ray and transesophageal echocardiographic guidance. Our initial experience, and that of others, indicates that transcatheter occlusion of secundum atrial septal defects is safe and effective and can be an appropriate alternative in approximately 60% of patients.
After spontaneously acquiring complete heart block, two children presented with torsade de pointes as a result of inappropriate prolongation of the QT interval. Although both remain well following pacemaker insertion, their cases illustrate the importance of QT interval assessment in patients with atrioventricular block, and demonstrate that syncopal episodes, and possibly sudden death, in children with acquired heart block can be due to bradycardia-induced ventricular tachyarrhythmias, rather than extreme bradycardia per se.
BACKGROUND: The use of endovascular stents to relieve obstructions in the setting of non-balloon dilatable pulmonary artery stenosis has been encouraging. The benefits in management and the potential for restenosis, however, have not been defined. This study attempts to assess the impact of such implants on clinical outcomes and the pattern of stent incorporation within the vessel wall. METHODS AND RESULTS: Fifty-five balloon-expandable stents were implanted in 42 patients 6.1 +/- 4.7 years of age. Patients were followed prospectively (median, 15 months) and recatheterized 1 year after implantation. Thirty-eight patients had the implants positioned percutaneously (49 implants), while 4 patients (6 implants) had intraoperative implantations. There was a diameter increase in the stenotic area of 109 +/- 79% (P < .0001) and a gradient reduction of 74 +/- 26% (P < .0001). Twelve stents straddled the orifice of side-branch pulmonary arteries and reduced flow to the branch vessel acutely in 7 patients. Twenty-nine patients underwent recatheterization, and various degrees and locations of acquired intraluminal narrowing were observed in all cases, particularly in areas of diameter mismatch between the stented and nonstented vessels. Eleven patients had further dilation with diameter improvement. Of the 38 patients who underwent percutaneous implantation, planned surgery for pulmonary artery stenosis was avoided in 33 and deferred in 4 patients. One patient who was considered inoperable had stent implantation as a palliative procedure. Symptomatic improvement was reported in 27 patients, and 15 patients remained asymptomatic. CONCLUSIONS: Endovascular stents have a role in the treatment of pulmonary artery stenoses and positively affect clinical care. The stenosis relief, however, may be tempered by the development of intraluminal stent obstruction, which may require redilation (15 of 55 stents) and mandates long-term follow-up.
The current electrocardiographic (ECG) definition of anteroseptal acute myocardial infarction (AMI) is a Q wave or QS wave > 0.03 second in leads V1 to V3, with or without involvement of lead V4. To verify whether there is a correlation between the ECG pattern of anteroseptal AMI and the location of an AMI, we compared ECG, echocardiographic, and cardiac catheterization findings of 80 patients who fit the traditional definition of anteroseptal AMI. We found that 48 of 52 patients (92%) who presented with ST elevation in leads V1 to V3 had an anteroapical infarct and a normal septum. The culprit narrowing was more frequently found (in 85% of patients) in the mid to distal left anterior descending artery. We conclude that there is no correlation and that the ECG pattern traditionally termed anteroseptal AMI should be called an anteroapical AMI; the term anteroseptal AMI should be defined as extensive anterior wall AMI associated with diffuse ST changes involving the anterior, lateral, and occasionally, inferior leads.
Tricyclic antidepressant (TCA) ingestions remain a serious and not uncommon overdose in children. In adults, a terminal 40 millisecond QRS vector (T40-ms) between 120 and 270 degrees has been proposed as a marker for TCA overdose; however, the normal rightward deviation and high incidence of incomplete right bundle branch block noted in the electrocardiograms (ECGs) of young children may limit the usefulness of this criterion in this population. A retrospective chart review of pediatric patients less than 11 years of age admitted to the Hospital for Sick Children with birth dates after 1971 identified by International Classification of Diseases, Ninth Edition, coding for TCA ingestion was undertaken, and data related to complications were collected and reviewed. The ECGs of 35 children presenting with TCA ingestion were examined by two blinded cardiologists and the T40-ms as well as QRS, QTc, and PR intervals were calculated and compared to those of 35 healthy age-matched controls undergoing routine ECGs. In the 35 children (aged 48 +/- 39 months [mean +/- SD]) with a history of TCA ingestion, symptoms were categorized as significant in 18 (51%), mild in 12 (34%), and none in five (14%). Seizures were present in 13 (37%), hypotension in three (9%), and arrhythmias in five (14%). The mean T40-ms axes in the TCA and control groups were 111 +/- 66 degrees and 97 +/- 71 degrees, respectively. A T40-ms between 120 and 270 degrees had a sensitivity of 38% and a specificity of 74%. A marked variability in the T40-ms was noted in both the exposed and control groups.(ABSTRACT TRUNCATED AT 250 WORDS)
A 4-week-old female infant presented with congestive heart failure, moderate mitral regurgitation, and an electrocardiographic pattern of anterolateral myocardial infarction. Angiography revealed normal coronary arteries and moderate mitral regurgitation. A single-catheter electrophysiology study confirmed the presence of an accessory atrioventricular conduction pathway.