[ECG in a child with acute ischemia of a lower member]

Acute ischemia of the upper and lower limbs is rarely encountered in Pediatrics. The most frequent causes are of embolic origin : intracardiac thrombosis in severe dilated cardiomyopathy, localized thrombosis at the tip of a central catheter or infective endocarditis. Here we report the contribution of ECG in the therapeutic management of a 4-year-old boy, admitted in the emergencies for acute ischemia of the left limb and occurring in an infectious context

Pulmonary artery accelerated flow revealing Hodgkin's lymphoma

We present a case in which transthoracic echocardiography was the first diagnostic tool to suspect mediastinal Hodgkin's lymphoma by revealing a change in the hemodynamic of left pulmonary artery flow, and it was used as a follow-up method for monitoring treatment efficacy by demonstrating a normalization of pulmonary artery hemodynamics

Supravalvular aortic stenosis with and without coronary lesions in pediatrics

This study aims to analyze several parameters concerning the supravalvular aortic stenosis [SVAS] in children such as age of diagnosis, place of residence, the existence of a metabolic disorder or dysmor-phic syndrome and possible damage to the coronary ostia, the means of diagnosis and outcome of these patients. A large group of patients [2868] with congenital heart disease enrolled between 1 May 1999 and 30 April 2010 at the National Register of Pediatric and Congenital Heart Disease, Lebanese Society of Cardiology. SVAS were found in 14 patients [0.5%] aged 8.5 months to 15 years. The Williams Beuren syndrome was the most common etiology [6 cases] without ostial stenosis, asymptomatic and not treated, followed by forms without dysmorphic syndrome [5 cases] and without ostial stenosis, one patient was operated because of severe SVAS ; finally, 3 cases of homozygous familial hypercholesterolemia treated differently: a patient had a successful liver transplantation at age of 4.5 years but has developed, despite the normalization of cholesterol level, a SVAS associated with severe ostial lesions 10 years after transplantation, another treated by coronary artery bypass graft surgery and the latter treated medically. SVAS is a very rare disease, but its discovery must lead to search for coronary lesions especially in presence of homozygous familial hypercholesterolemia. The ultrasound monitoring is mandatory and is designed to detect this anomaly and early coronary lesions. The slightest suspicion should carry out more extensive explorations to detect ostial stenosis

False and true acute rheumatic fever A Lebanese experience

Objectives: The main aim of this study is to evaluate the significance of several clinical and laboratory findings presented by a large number of pediatric patients who were suspected to have acute rheumatic fever [ARF] by physicians who ordered echocardiogram for confirmation and for avoiding overuse of unnecessary antibiotics. These suspecting reasons include elevated ASO titers and recurrent tonsillitis. Another aim is to stress the role of Doppler echocardiogram in confirming the diagnosis of ARF by detecting rheumatic heart disease [RHD] in suspected cases

Materials and Methods : 401 patients were registered in the National Registry of the Pediatric and Congenital Heart Disease [RNCPC] from April 1, 2002 until the end of March 2013 as suspected cases of ARF. The clinical reasons that brought suspicion are discussed and evaluated in accordance to modified Jones criteria. The patients are distributed into two groups : 1] confirmed ARF and 2] different diagnosis. All patients underwent echocardiogram. Patients came from different geographic areas and were referred by a variety of physicians

Results : 48 patients out of 401 suspected cases turned to have confirmed ARF [12%]. In this group, the predominant suspecting reasons are reported as heart murmur in 29/48 [60.4%], arthritis in 28/48 [58.3%], arthralgia with reduced physical activity in 15/48 [31%] and chorea in 5/48 [10%]. In the different diagnosis group with a high ASO titer 174/353 [49.3%], isolated arthralgia 91/353 [25.8%] and combined elevated ASO with arthralgia in 44/353 [12.5%] were the predominant suspecting reasons. Doppler echocardiography could detect 38/48 cases of active carditis and subclinical carditis [SCC]

Conclusion: Heart murmur, arthritis, arthralgia with reduced physical activity and chorea are the main clinical reasons that lead to suspicion in the ARF group. High ASO titers, arthralgia, and combination of high ASO titers with arthralgia are the main presenting symptoms in the group with a different diagnosis. We concluded that elevated ASO titer and normal ESR with arthralgia not reducing physical activity can exclude ARF. Doppler echocardiography is found to be a gold standard key to confirm acute rheumatic heart disease and ARF

[Regression spontanee de la coarctation de l'aorte chez le nourrisson]

Coarctation of the aorta in neonates and small infants is, in most cases, a severe congenital malformation and requires a rapid surgical treatment or interventional catheterization. To our knowledge, and so far, no cases of coarctation of the aorta have spontaneously improved. We report three cases of coarctation diagnosed in young infants and considered as moderate forms on physical exam and/or ultrasound study which evolved to partial or complete regression without any treatment

silent patent ductus arteriosus

To describe the characteristics and outcome of children with an isolated silent patent ductus arteriosus [SPDA], with comparison to non-silent ducts. Between 1999 and 2004, all consecutive cases of isolated silent and non-silent-patent ductus were recorded at the National Register of Pediatric and Congenital Heart Disease, Lebanese Society of Cardiology. Patients with a SPDA were followed clinically and by Doppler echocardiography while all non-SPDA were percutaneously or surgically closed. Twenty-four cases of isolated SPDA and 50 cases of isolated non-SPDA ducts were recorded. Male sex was significantly predominant in the silent group [70%]. First-cousin consanguinity rates were not different between both groups, with 20.4% for the silent group versus 22% for the non-silent group. Down's syndrome was associated in three cases of SPDA. No cases of endocarditis were noted during a mean follow-up of 33.3 months. Four patients with a SPDA experienced spontaneous closure at the age of 25,30,36 and 58 months. SPDA is a relatively benign disease. The risk of endocarditis cannot be totally ignored, but the systematic closure of the SPDA is not warranted. Larger series and longer follow-up are needed in order to draw conclusions. Spontaneous closure occurred in four patients with SPDA

Cardiopathie congenitale, age maternel et consanguinite parent ale chez les enfants avec syndrome de down

Analyze the role of parental consanguinity and/or maternal age on the occurrence of congenital cardiac anomalies in infants with Down's syndrome [DS]. A large group of patients with or without congenital heart disease, registered between May 1[st], 1999 and June 30[th], 2006, at the National Register of Paediatric and Congenital Heart Disease, Lebanese Society of Cardiology. 217 children with DS have been enrolled over this period. Group I: DS with cardiac anomalies [n: 119]. Group II: DS without cardiac anomalies [n: 98]. The consanguinity rate was compared to a study made in 2000 by UNICEF in Lebanon, in which the consanguinity rate was 14.9% of 1st degree cousins and 25% of all degrees together. Congenital cardiac anomalies were found in 54.2% of babies with DS. First degree cousins in both groups I and II was 143% [close to the general population], and it was lower in group I compared to group II [11.8% and 17.3% respectively ; p = 0.205] ; this difference was not statistically significant for all degrees together. Maternal age ranged from 20 to 47 years, with a mean of 29.5 +/- 5.3 years. The risk of congenital cardiac anomaly was greater [p < 0.05] when maternal age was equal or below 32 years. As in the international literature, complete atrioventricular canal and ventricular septal defect were the most frequent cardiac anomalies. In children with DS, the risk of congenital cardiac anomalies was not associated with the parents consanguinity. Maternal age above 32 years seem to be associated with a lesser occurrence of congenital cardiac anomaly in children with DS

Assessment of the reasons prompting a first echocardiography in children: a Lebanese multicenter study

To study the different indications behind performance of a first Doppler echocardiography [DE] in children, to assess the results and their impact on the residency teaching program in Lebanon. Retrospective study over a 40-month period, from March 1[st], 2002, through June 30, 2005. Patients referred for the first DE were examined in different medical centers in Beirut, Mount-Lebanon and South Lebanon. 3137 new patients aged from 0 to 18 years [average: 54 months] were included in the analysis. The percentage of patients seen as outpatients was 48% in departments of pediatrics and emergency rooms: 38.2%; intensive care neonatal units: 13%; and in maternity wards/nurseries: 0.8%. 2198 patients [70.1%] had normal DE. Heart murmur accounts for 45.6% of DE requests, followed by extracardiac malformations and presence of dysmorphic features [7.2%], cyanosis [6.8%], suspicion of rheumatic fever [5.7%], cardiac arrhythmia [3.8%], bronchopneumopathies and respiratory distress [3.5%], chest pain and palpitations [3.3%]. Innocent murmur was found in 53.9% of patients referred for heart murmur among syndromes and malformations, Down's syndrome was the most frequent pathology, followed by poly malformations, the VACTERL syndrome and the cleft lip and palate. Cyanotic congenital heart disease was diagnosed in 34% of cases referred for cyanosis. The diagnosis of carditis was confirmed in 84.6% of children with clinical picture of rheumatic fever. In cases of malaise, dizziness and loss of consciousness, no abnormality was detected on DE. DE should be a complement to clinical exam, which is often sufficient to reveal a cardiac pathology. However, some conditions, where cardiovascular exam is normal require a DE. The question of when and why to request a DE must be a priority in the pediatric resident training program

[Cardiogenic shock revealing heart disease in infancy and childhood]

Diagnosis, initial workup and immediate prognosis in congenital or acquired heart diseases revealed by cardiogenic shock [CS] in a Lebanese paediatric multicentric study. During a six-year period [is. January 1999 to 31 December 2004], 56 paediatric patients aged between 0 and 7 years have been admitted to the emergency departments or neonatal and intensive care units in ten different Lebanese hospitals, for high degree of CS suspicion with underlying cardiac disease. All diagnoses were confirmed by echocardiography.All children were initially in a critical condition with signs of CS. Congenital heart diseases [CHD], specially left obstructive diseases [coarctation of the aorta, critical aortic stenosis, hypoplastic left heart syndrome] were the main etiologies found in newborns, followed by dilated cardiomyopathies in infants and children. Mortality was higher in the following two groups of patients : intubation, no diuresis after the first hour of admission despite therapeutic measures [prostaglandines in newborns, dopamine, dobutamine and furosemide]. Beside those pathologies necessitating specific treatment, all the CHD [excluding hypoplastic left heart syndrome, one case of critical aortic coarctation and one case of congenital mitral regurgitation] were transferred to the catheterization laboratory or to surgery in a good hemodynamic condition. CS remains a notable medical problem observed in the emergency and paediatric intensive care units in Lebanon. Immediate prognosis is related to : immediate recognition of the CS, nature of the car-diopathy and initial response to therapeutic procedures such as rapid improvement of respiratory status and rapid diuresis. Echocardiography is a reliable, quick and non-invasive procedure for initial diagnosis

[Salmonella Typhi in a child with urinary tract infection and Urolithiasis]

Salmonella species are a rare cause of urinary tract infections in children. They have been associated with a higher incidence of structural abnormalities or immunosuppressive status. We report the case of an 11-year-old girl with urinary tract infection [UTI] secondary to Salmonella typhi and associated with urolithiasis. A review of the subject is then discussed

Fermeture percutanee des communications interauriculaires par la prothese Amplatzer

Percutaneous closure of an atrial septal detect [ASD] was undertaken in 10 patients aged from 3 to 33 years. The Amplatxer device was introduced intravenously and positioned under fluoroscopic and echographic control. the size of the ASD varied from 13 to 20 mm and that of the devices from 15 to 32 mm. one patient was operated for the removal of an improperly positioned device and closure of the ASD. All the other patients were discharged 24 hours after the procedure with successfull closure of the ASD. Complications were benign: spontaneously regressive arrhythmias [1 case] and migraines [2 cases]. our series reflects the experience of others, showing the faisability and efficiency of the procedure. tridimensionnal or intracardiac echocardiography may improve this technique in the future

echocardiographie set une technique utile dans un service de soins intensifs neonatals: experience Libanaise

To study the role of Doppler Echocardiography [DE], its indications and results in multiple neonatal intensive care units [NICU]. materials and methods: Over a period of 12 months, starting November 1st, 2001, till October 31st, 2002, 1105 newborns were admitted to six different NICU centers in the city of Beirut and its southern suburb. DE was requested in 159 patients [14.4%] mainly for the suspicion of hemodynamic disorders [congenital cardiopathy [cc], pulmonary hypertension [PHT], un-explained respiratory distress, shock and cardio-respiratory arrest. Through this examination, the following were investigated [search for cc; study of the cardiac contractility; search and study of the blood flow through the foramen ovale [FO] and the ductus arteriosus [DA] if patent; detection of mitral and tricuspid regurgitation [MR, TR]; measure, if possible, of the systolic pulmonary artery pressure, and eventual estimation of the systolic pressure in the aorta], Congenital heart disease was diagnosed in 53 newborns [33.3%], secondary PHT in 14 [8.8%], ischemic cardiomyopathy in 4, persistent fetal circulation in 3. DE was normal in 81 patients [50.9%]. In 123 completely documented cases, a FO was constantly patent, TR was found in 52% allowing the-measure of pulmonary artery pressure, a patent DA in 49%; the systemic arterial pressure was estimated in 35% and MR was noted in 5% of the cases. Not to consider the cc, DE is indicated in numerous situations. This technique permits precise study of the cardiovascular functions, mainly in critical situations; it allows the follow-up of the hemodynamic modifications instantaneously under treatment. Actually, the neonatal resuscitation and the critical modifications necessary in the workup of newborns mandate the presence of a DE machine in the NICU. Furthermore, DE knowledge should be incorporated in the future training programs of physicians specializing in neonatal resuscitation

Fermeture percutanee du canal arteriel chez l'enfant une premiere serie au Liban

Percutaneous closure of the patent ductus arteriosus [PDA] has become an efficient and safe technique in children. We report the first Lebanese series of 8 children who had their PDA closed percutaneously with a coil or an Amplatxer Duct Occluder. Patients median age was 3.2 years [range 1.2 to 12 years]. The median minimal diameter of the PDA was 2.1 mm [1.2 to 4 mm]. A coil was used in 4 children and an Amplatxer occluder in the 4 other patients. The device was chosen according to the diameter of The PDA The results were excellent in all patients. A trivial shunt present in 3 cases, disappeared within 8 weeks. No complication were noted in this series. Percutaneous closure of the PDA in children, using interventional radiology, is a simple and reproducible technique. It is now the treatment of choice in most pediatric cardiac centers worldwide

Cardites in infra-cliniques lors d'une premiere poussee de rhumatisme articulaire aigu: interet de l'echocardiographie-doppler couleur et incidences therapeutiques

To determine and to evaluate valvular involvement, in particular subclinical, as confirmed by colored Doppler echocardiography [CDE] during an initial attack of acute rheumatic fever [ARF]. Means of diagnosis and therapeutic implications. materials and methods Over a 7-year period, from January 1994 to December 2000, 49 patients [27 females and 22 males], with a mean age of 9.2 years [range 5-14 years], who presented with a first attack of ARF, were diagnosed on the basis of clinical data [history, physical findings, specific laboratory data, EKG, and CDE] to determine the major and minor criteria of acute rheumatic fever. All patients were reinvestigated and controlled clinically and by echocardiography two weeks to three months after the first investigation.results Reported clinical major criteria were Arthritis, 46 cases [94%]; carditis, 27 cases [55%]; erythema marginatum, 3 cases [6%]; subcutaneous nodules, 3 cases [6%] and chorea, 3 cases [6%].CDE abnormalities were identified in 37 cases with cardiac involvement [75% of patients], 10 of them had subclinical evidence of valvular involvement 6 cases with mild to moderate mitral regurgitation [MR], 2 cases with moderate aortic regurgitation [AR], and 2 cases had both mild to moderate MR and moderate AR. All patients with subclinical disease and evidence of inflammatory process [7 cases] were treated by salicylates. Repeated echocardiography for control showed disappearance of valvular insufficiency in 8 patients with subclinical valvulopathy, and aggravation was observed in 2 other patients.conclusion CDE is recommended in patients with suspicion of ARF, even in normal cardiac auscultation in order to detect an acute cardiac involvement leading to an early diagnosis. The confirmation of subclinical valvular disease should be considered as major criteria for ARF. Isolated and subclinical mitral and/or aortic regurgitations, with evidence of inflammatory process, should, receive corticosteroids and be followed-up regularly, clinically and non-invasively by CDE