Diagnostic value and misdiagnosis analysis of tetralogy of Fallot by prenatal echocardiography / 中华实用儿科临床杂志

Objective To evaluate the diagnostic value of prenatal echocardiography in fetus with tetralogy of Fallot(TOF),and to analyze the reason of misdiagnosed in order to improve the echocardiographic diagnosis.Methods A retrospective echocardiographic review of 36 fetuses with TOF confirmed by prenatal magnetic resonance imaging (MRI) or postnatal echocardiography.Results Among 36 cases of TOF fetuses,31 cases (86.1 ％) were diagnosed correctly by echocardiography,and in the remaining 5 cases,4 cases(11.1％) were misdiagnosed [2 cases misdiagnosed as ventricular septal defects (VSD),2 cases misdiagnosed as double outlet of right ventricles],and 1 case (2.8％) was missed diagnoses at 20 weeks gestation and confirmed as TOF at 36 weeks gestation based on the echocardiographic findings of malalignment type VSD,overriding aorta,pulmonary stenosis,and right ventricular hypertrophy.Malalignment type VSD,overriding aorta,and pulmonary stenosis were observed in 31 cases with TOF diagnosed by prenatal echocardiography,right ventricular hypertrophy was observed only in 6 cases.The most common associated anomalies were tricuspid regurgitation in 13 cases(36.1％),aortic insufficient in 6 cases(16.7％),absent pulmonary valve in 4 cases(11.1％),right-side aortic arch in 4 cases(11.1％),persistent left superior vena cava in 3 cases(8.3％),and complete atrioventricular septal defect in 1 case (2.8％).Conclusions Combining visualization of TOF in four-chamber view,outflow tract view,and three vessels view,TOF can be accurately diagnosed by prenatal echocardiography.

Clinical presentation and therapeutic outcomes of carnitine deficiency-induced cardiomyopathy / 中华儿科杂志

<p><b>OBJECTIVE</b>Carnitine deficiency has been associated with progressive cardiomyopathy due to compromised energy metabolism. The objective of this study was to investigate clinical features of carnitine deficiency-induced cardiomyopathy and the therapeutic efficacy of L-carnitine administration.</p><p><b>METHOD</b>Between January 2010 and December 2011, filter-paper blood spots were collected from 75 children with cardiomyopathy. Free carnitine and acylcarnitine profiles were measured for each individual by tandem mass spectrometry (MS/MS). For those in whom carnitine deficiency was demonstrated, treatment was begun with L-carnitine at a dose of 150 - 250 mg/(kg·d). Clinical evaluation, including physical examination, electrocardiography, chest x-ray, echocardiography and tandem mass spectrometry, was performed before therapy and during follow-up.</p><p><b>RESULT</b>Of 75 cardiomyopathy patients, the diagnosis of carnitine deficiency was confirmed in 6 patients, which included 1 boy and 5 girls. Their age ranged from 0.75 to 6 years. Free carnitine content was (1.55 ± 0.61) µmol/L (reference range 10 - 60 µmol/L). Left ventricular end-diastolic diameter (LVDd) was (5.04 ± 0.66) cm and left ventricular ejection fraction (LVEF) was (38.5 ± 10.5)%. After 10 - 30 d therapy of L-carnitine, free carnitine content rose to (30.59 ± 15.02) µmol/L (t = 4.79, P < 0.01). LVDd decreased to (4.42 ± 0.67) cm (t = 4.28, P < 0.01) and LVEF increased to (49.1 ± 7.6)% (t = 6.59, P < 0.01). All patients received follow-up evaluations beyond 6 months of treatment. Clinical improvement was dramatic. LVEF returned to normal completely in all the 6 patients. LVDd decreased further in all the 6 patients and returned to normal levels in 3 patients. No clinical signs or symptoms were present in any of the 6 patients. The only complications of therapy had been intermittent diarrhea in 1 patient.</p><p><b>CONCLUSION</b>Tandem mass spectrometry is helpful to diagnose carnitine deficiency and should be performed in all children with cardiomyopathy. L-carnitine has a good therapeutic effect on carnitine deficiency-induced cardiomyopathy.</p>

Epidemiologic features of Kawasaki disease in Shanghai from 2003 through 2007 / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The epidemiologic pictures of Kawasaki disease (KD) in Shanghai from 1998 through 2002 were reported, while the current status of KD in the following five years remains unknown.</p><p><b>METHODS</b>A questionnaire form and diagnostic guidelines for KD were sent to 50 hospitals providing pediatric medical care in Shanghai, China. All patients with KD diagnosed during January 2003 through December 2007 were recruited.</p><p><b>RESULTS</b>In total, 1187 cases of KD were enrolled. The incidence of KD was 36.78 to 53.28 (mean 46.32 ± 6.51) per 100 000 children under the age of 5 years between 2003 and 2007, which was higher than the year from 1998 to 2002 of (27.32 ± 7.11) per 100 000, (t = 4.406, P = 0.002). Ages at onset ranged from 12 days to 13.6 years (median 1.8 years). It occurred more frequently in summer and spring. Coronary arterial lesions (CAL), defined as ectasia or aneurysm, accounted for 19.8% (232 cases). Flattened or inverted T wave was the most frequent finding (194 cases, 20.5%) by electrocardiogram. Intravenous gamma-globulin was administrated to 1028 cases (86.6%). The occurrence of CAL seemed less frequent in the patients received gamma-globulin from day 5 to day 9 after the onset with the regimen of 1000 mg/kg once or 1000 mg/kg twice.</p><p><b>CONCLUSIONS</b>The incidence of KD was increasing in Shanghai. Treatment with intravenous gamma-globulin from day 5 to day 9 after the onset with the regimen of 1000 mg/kg once or 1000 mg/kg twice resulted in less coronary sequelae.</p>

Current status of the management of pediatric infective endocarditis: a national survey / 中华儿科杂志

<p><b>OBJECTIVE</b>During recent years several changes have occurred in the clinical characteristics of infective endocarditis (IE) which has made a new challenge in the management of this disease. This study aimed to understand current practice pattern in the management of pediatric IE in China.</p><p><b>METHODS</b>This retrospective, multicenter study was conducted in 13 hospitals. Clinical data of 268 patients diagnosed as IE according to the new IE criteria (trial) between 2000 and 2006 were analysed, focusing particularly on management and outcome of patients. The mean age of patients was 8.94 years (18 d - 18 years).</p><p><b>RESULTS</b>Except for one patient who died after admission without treatment, 56 antimicrobial agents were used in the management of this disease in the 267 patients, including cephalosporin group (15), penicillin group (8), beta-lactamase inhibitor combination (8), aminoglycosides (4), glycopeptide agents (3) etc. The most commonly used antibiotics were as follows: penicillin G (125 cases/times), cefotaxime (113), vancomycin (78), ceftriaxone (73), ampicillin (66), cefuroxime (56), piperacillin (48), amikacin (39) etc. For management of this disease, only one antibiotic agent was used in 33 (12.3%) patients, two antibiotic agents in 83 (31.1%) patients, 3 antibiotic agents in 44 (16.5%) patients, 4 antibiotic agents in 57 (21.3%) patients, 5 antibiotic agents in 25 (9.4%) patients, 6 or more antibiotic agents in 25 (9.4%) patients. The most commonly used antibiotic agents in patients with streptococci detected in blood culture were penicillin G, cephalosporins, vancomycin, beta-lactamase inhibitor combination, and aminoglycoside, in patients with staphylococcus detected in blood culture were cephalosporins, oxacillin, vancomycin, aminoglycoside, and quinolones. Duration of antibiotic treatment was from 1 day to 98 days, less than 2 weeks in 19 (7%) patients, 2 weeks to less than 4 weeks in 74 (27.7%) patients, 4-6 weeks in 122 (45.7%) patients, more than 6 weeks in 52 (19.4%) patients; 123 patients simultaneously underwent surgical management (for removal of vegetations and intracardiac defects or residual shunt repair 105, and valve repair 8, valve replacement 6, intracardiac defect repair 4 ) Of the 268 patients, 186 patients were cured, 4 patients were referred to surgery, 18 patients died and 60 patients refused medical advice. In antibiotics and surgical treatment group (123 patients), 111 patients were cured, 4 patients were referred to surgery, 5 patients died, 3 patients refused medical advice, in antibiotics treatment group (145 patients), 75 patients were cured, 13 patients died, 57 patients refused medical advice. The outcomes were significantly different between the two groups (chi2 = 61.7, P = 0.000). The results of multivariate logistic regression analysis showed that Staphylococcus aureus as a pathogen (chi2 = 4.40, P = 0.036, OR = 9.78, 95% CI 1.16-82.26), children with repaired congenital heart disease (chi2 = 9.4, P = 0.002, OR = 9.8, 95% CI 2.28-42.16), and complicated with heart failure (chi2 = 10.36, P = 0.001, OR = 0.075, 95% CI 0.16-0.36) were risk factors related to death.</p><p><b>CONCLUSION</b>This study revealed the current status in the management of pediatric IE in China Wide range antibiotic agents and diverse regimens are used to manage children with IE. For improving management of pediatric IE, there is an urgent need for guidelines or recommendations or consensus for management of pediatric IE stipulated by multidiscipline specialists, and randomized controlled clinical trials are required to provide evidences.</p>

Noninvasive preoperative estimation of pulmonary vascular resistance of the patients waiting for two staged Fontan procedure / 中华儿科杂志

<p><b>OBJECTIVE</b>Noninvasive method for estimating the pulmonary vascular resistance (PVR) was used in patients waiting for two staged Fontan procedure to observe the relationship between estimated PVR and surgical results.</p><p><b>METHODS</b>Thirty-three candidate patients for two staged Fontan procedures were randomly selected for this trial. Preoperative hemoglobin (HGB), hematocrit (HCT) and pulse oxygen saturation (SpO2) were measured. Estimated PVRs were then calculated by the regression equations. The cases were divided into three groups of low risk group with PVR less than 2.4 wood, high risk group with PVR between 2.4 to 3.2 wood, and extremely high risk group with PVR more than 3.2 wood. The incidences of postoperative low cardiac output and multi-organ failure were compared. Simultaneously, the cases without or with postoperative severe low cardiac output and multi-organ failure after operation were divided into two groups. The preoperative HGB, HCT and estimated PVR among the groups were analyzed.</p><p><b>RESULTS</b>The rates of postoperative severe low cardiac output and multi-organ failure were 10.0%, 32.4% and 63.6% for the patients of low, high and extremely high risk groups respectively. The difference was significant (P < 0.01). The preoperative HGB, HCT, SpO2 and PVR were all significantly different between the patients without or with postoperative severe low cardiac output and multi-organ failure. The PVR (HGB) were (2.53 +/- 0.56) wood and (3.24 +/- 0.58) wood respectively. The PVR (HCT) were (2.59 +/- 0.58) wood and (3.21 +/- 0.79) wood respectively. The PVR (SpO2) were (2.22 +/- 0.55) wood and (2.93 +/- 0.58) wood, respectively. The differences were all significant (t = 3.25, 2.52 and 3.33 respectively, P < 0.01 or 0.05).</p><p><b>CONCLUSIONS</b>Preoperative estimated PVRs calculated by HGB, HCT and SpO2 were comparable with the postoperative results. Thus, the invasive preoperative estimation of pulmonary vascular resistance could be a method in estimating the surgical indication and predicting the surgical result for two stage Fontan procedure.</p>

Evaluation of the development of pulmonary vessels with pulmonary venous index in congenital heart disease with decreased pulmonary blood flow / 中华儿科杂志

<p><b>OBJECTIVE</b>The development status of pulmonary artery is one of the most important criteria for decision-making strategy and predicting postoperative outcome in congenital heart disease with decreased pulmonary blood flow. Currently, Nakata index and McGoon index have been used as morphologic index in evaluating the development status of pulmonary artery. Those indices have some shortcoming. It was recently found that pulmonary veins index is a more precise morphological indicator of pulmonary blood flow and development status of pulmonary vessels. This study aimed to explore an index of evaluating pulmonary blood stream and the development of pulmonary vessels, as a criterion for surgical decision-making strategy.</p><p><b>METHODS</b>The diameters of left and right pulmonary arteries and pulmonary veins were measured on DSA films in 74 patients with congenital heart disease with decreased pulmonary blood flow, The correlative analysis was done between Nakata index, McGoon index, pulmonary vein index (PVI) and postoperative outcome which were the length of stay in ICU, duration of mechanical ventilation and dose of inotropic drugs.</p><p><b>RESULTS</b>Excellent correlations between the size of pulmonary veins and pulmonary arteries were found, the correlation between left pulmonary veins and distal portion of left pulmonary artery was 0.73, between left pulmonary veins and proximal portion of left pulmonary artery was 0.72, right pulmonary veins and distal portion of right pulmonary artery was 0.67, and right pulmonary veins and proximal portion of right pulmonary artery was 0.71. The length of stay in ICU, duration of mechanical ventilation and dose of inotropic drugs correlated well with PVI (r = -0.51, -0.478, and -0.693). Compared with Nakata index and McGoon index, PVI was a better criterion for evaluating the developmental status of the whole pulmonary vessels. In the right ventricular outlet reconstruction patients, the McGoon index for patients with low cardiac output syndrome (LCOS) was 1.36 +/- 0.51, and 1.97 +/- 0.58 for patients without LCOS (t = 2.347, P < 0.05), the Nakata index for patients with LCOS was 164 +/- 106 mm(2)/m(2) and 269 +/- 124 mm(2)/m(2) for patients without LCOS (t = 2.218, P < 0.05), the PVI for patients with LCOS was 152 +/- 77 mm(2)/m(2) and 273 +/- 125 mm(2)/m(2) for patients without LCOS (t = 2.936, P < 0.01), pulmonary vessel index of patients with LCOS was less than that of those without LCOS. When PVI was < or = 180 mm(2)/m(2), postoperative hemodynamics was unstable, the frequency of low cardiac output syndrome and mortality significantly increased.</p><p><b>CONCLUSIONS</b>The development of pulmonary arteries and pulmonary veins correlated with each other. PVI is a precise morphological indicator of pulmonary blood flow and development of pulmonary vessels. It is a helpful indicator to decide surgical strategy.</p>

Diagnostic value of the currently used criteria and brain natriuretic peptide for diagnosing congestive heart failure in children with congenital heart disease / 中华儿科杂志

<p><b>OBJECTIVE</b>To improve the accuracy of diagnosis of heart failure (HF) has been the focus of research for a long time. The diagnosis for HF with congenital heart disease, however, is more difficult. The aim of the study was to evaluate the diagnostic criteria for HF in children and examine the value of plasma brain natriuretic peptide (BNP) and NT-proBNP for diagnosing HF in pediatric patients with congenital heart disease, and to look for the most valuable index for the diagnosis according to the multifactor analysis.</p><p><b>METHODS</b>Totally 118 children with congenital heart disease were enrolled. They were diagnosed using modified Ross score, Qingdao criteria, NYU PHFI, and plasma BNP and NT-proBNP. According to modified Ross score as the referent criteria, other diagnostic criteria and plasma BNP and NT-proBNP were studied. The sensitivity, specificity and area of the ROC curve were examined. Logistic regression analysis was used to select the valuable index for diagnosing HF.</p><p><b>RESULTS</b>(1) The value of each clinical criteria: 1 The sensitivity of Qingdao criteria for diagnosing HF was 47.9%. The specificity was 100% and the accuracy was 57.6%. 2 There were 52 patients younger than six months in whom 27 (51.9%) were breast fed. Only 25 children were measured with Ross score. The Ross score was positively correlated with the modified Ross score (r = 0.948). The area under the ROC curve of Ross score diagnosing HF was 0.985, and the sensitivity was 88%, while the specificity was 100%. 3 NYU PHFI score was positively correlated with the modified Ross score. The area under the ROC curve of the NYU PHFI diagnosing HF was 0.964, and the sum of sensitivity and specificity was favorite when > or = 8 was set as the cut-off point. If > 2 was set as cut-off point, it had a high sensitivity but a low specificity. The sensitivity of NYU PHFI was 100% > was set 2 as cut-point for diagnosing HF, but the specificity was 4.5%. (2) Plasma BNP and NT-proBNP were positively correlated with the modified Ross score, and increased with the severity of congestive HF. The area under the ROC curve of BNP was 0.880, and the cut-off line was > or = 349 pg/ml. The area under the ROC curve of NT-proBNP was 0.981, and the cut-off line was > or = 499 fmol/ml. (3) Logistic regression analysis showed that in multifactor analysis, only plasma concentration of NT-proBNP, dyspnea, tachycardia, tachypnea, failure to thrive were the independent predictors for diagnosing HF. (4) Plasma concentration of NT-proBNP incorporated with clinical criteria would improve its accuracy.</p><p><b>CONCLUSION</b>All the clinical criteria commonly used were valuable for diagnosing HF in children with congenital heart disease, but each has its own limits, such as the low sensitivity of Qingdao, the low adaptation of Ross score because of the high breast-feeding rate in our country and the low specificity of NYU PHFI when > 2 was set as the cut-off point. Plasma concentrations of BNP and NT-proBNP were valuable for diagnosing HF in children with congenital heart disease, and NT-proBNP was the independent predictor for HF.</p>

Pathological diagnosis of conotruncal defects by transthoracic three-dimensional echocardiography / 中华儿科杂志

<p><b>OBJECTIVE</b>Recently, it has been demonstrated in several studies that three-dimensional echocardiography (3DE) with any cut view interpretation of the cardiac morphological structures and its dynamic three-dimensional display can conform to the need of accurate anatomical diagnosis of complex congenital heart diseases including conotruncal defects (CTD). 3DE can not only provide functional and morphological information of CTD to decide on surgical repair but also simulate the intra operative visualization of complex anatomical cardiac structures to improve the understanding of the anatomy of CTD, but there have been scarce studies to assess systematically the potential noninvasive diagnostic value of transthoracic 3DE for CTD in children. Thus, this study attempted to evaluate the diagnostic value of transthoracic 3DE for the pathological diagnosis of CTD in children.</p><p><b>METHODS</b>HP Sonos 5500 echocardiographic system interfaced with Tomtec 3DE imaging system (echo-view 4.2 software) was used to diagnose 210 patients (132 male, 78 female, aged 0-15 years, mean 3.2 +/- 3.2 years) with CTD in Shanghai Children's Medical Center from May 2000 to November 2003, including 62 patients with double outlet right ventricle, 48 patients with transposition of great arteries, 48 patients with tetralogy of Fallot, 38 patients with pulmonary atresia with interventricular septal defect and 14 patients with persistent truncus arteriosus. Diagnostic method consisting of ten designed 3DE sectional views and Van Praagh's sequential segmental approach in congenital heart diseases was used in this study. And the results were compared with those diagnosed by two-dimensional echocardiography (2DE) and angiocardiography. Surgical findings were considered as the "gold standard".</p><p><b>RESULTS</b>There were 526 image acquisitions of transthoracic 3DE in the 210 patients with CTD including 200 through subcostal window, 254 through parasternal window and 72 through apical window, among which 477 image acquisitions (93.2%) could demonstrate good spatial cardiovascular structures. Meanwhile, six 3DE sectional views of the diagnostic method of the ten designed 3DE sectional views were identified for the diagnosis of CTD as follows: en-face view of atrial and ventricular septa from left ventricle (L1a); en-face view of atrial and ventricular septa from right ventricle (L2a); four-chamber view of whole-heart oblique frontal plane (Ha and Hb); en-face view of atrial-ventricular valve from atria (S1a) and en-face view of atrial-ventricular valve from ventricles (S2a). The 3DE sectional diagnosis showed that 3DE could provide more information of inner cardiac structure than 2DE, such as ventricular configuration identification, atrial-ventricular and ventricular-arterial continuity, location and shape of ventricular septal defect (VSD), and appreciation of the defects related with aorta and pulmonary arteries, etc. In 147 cases of surgical repair, both 3DE and 2DE were in accordance with the surgical findings, but 3DE had new findings in 18 (12.2%) cases and corrected the diagnoses in 10 (6.8%) cases as compared with 2DE.</p><p><b>CONCLUSION</b>The 3DE sectional diagnostic method could make a successfully sectional diagnosis of pathological morphology in CTD by demonstrating more spatial information of inner cardiac structure than 2DE and angiocardiography.</p>

Spatial expression of cardiac alpha-actin during heart development in embryos / 中华儿科杂志

<p><b>OBJECTIVE</b>Conotruncal defects (CTD) is a common type of cyanotic congenital heart defects. It was shown that CTD might be produced by ablation of cardiac neural crest during early stage embryos in experimental studies. There were many kinds of genes involved and cardiac alpha-actin (CAA) was one of them. The purpose of this study was to investigate the spatial expression of CAA gene during embryonic heart development, and to explore its role in the pathogenesis of congenital heart defects.</p><p><b>METHODS</b>Experimental chicken embryos were subjected to cardiac neural crest ablation by using electric stimulation at 36-40 hr incubation stage. The embryos and organs of experimental and normal control groups during different developing periods were taken out, RNA was extracted by Trizol, and then reverse transcription was done. The dynamic changes of CAA mRNA expression at different development stages of embryos were assayed by fluorescent real-time PCR. The embryos and tissues at different stages were taken out, and paraffin sections were made. The localizations of CAA antibody expression in the developmental embryos were detected by immunohistochemical analysis (peroxidase-DAB coloration).</p><p><b>RESULTS</b>(1) The expression of CAA gene was detected at early embryo development, and increased subsequently to a stable level. Its expression was mainly limited to heart site, and could be increased along with the maturation of the cardiac muscle. There was no expression or little trace expression in liver, brain, and stomach. (2) There was a significantly low level of CAA gene expression on days 2-7 of chicken embryos whose cardiac neural crest were ablated in comparison with normal controls (P = 0.013). The level of CAA gene expression was also down-regulated on days 7, 9 and 15 of embryonic cardiac tissues (P = 0.029).</p><p><b>CONCLUSION</b>CAA gene is closely associated with heart development, its expression was adjusted by cardiac neural crest, and its dysfunction may be an important factor leading to congenital heart defects.</p>

Diagnostic value of plasma concentration of pro-brain natriuretic peptide in congestive heart failure in pediatric patients with ventricular septal defects / 中华儿科杂志

<p><b>OBJECTIVE</b>The value of plasma brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) can reflect cardiac function and therefore can be used for diagnosing congestive heart failure (CHF) and evaluating cardiac function. There are few reports, however, on the value of BNP and NT-proBNP in pediatric cases of congenital heart defect. The aim of this study was to assess the value of plasma NT-proBNP in the diagnosis of CHF and evaluation of cardiac function in pediatric patients with ventricular septal defect (VSD).</p><p><b>METHODS</b>Fifty-one patients with VSD aged from 2 months to 2 years old (mean 7.9 months) were enrolled. According to the modified Ross Score, the patients were divided into three groups, no CHF group (20 patients), mild CHF group (18 patients) and moderate to severe CHF group (13 patients). Fifteen age-matched normal children were used as controls. Plasma NT-proBNP was measured using enzyme immunoassay. All patients had complete echocardiographic study, including measurement of left ventricular end diastolic volume index (LVEDVI), left ventricular end systolic wall stress (LVSEWS), heart rate corrected mean velocity of circumferential fiber shortening (mVcFc), left ventricular ejection fraction (LVEF), left ventricular fractional shortening (LVFS), and contractility index (Con). The correlation between plasma NT-proBNP level and modified Ross Score and echocardiographic cardiac functional indexes was determined. The sensitivity, specificity and ROC curve of plasma NT-proBNP for diagnosing CHF was studied.</p><p><b>RESULTS</b>Plasma NT-proBNP was positively correlated with modified Ross Score (r = 0.75, P < 0.01). Plasma NT-proBNP concentration in moderate to severe CHF group (2061 +/- 908) fmol/ml was significantly higher than that of mild CHF group (810 +/- 335) fmol/ml, and Plasma NT-proBNP concentration in mild CHF group was higher than that in no CHF group (309 +/- 68) fmol/ml. 97.14% of normal controls and subjects in no CHF group had their plasma NT-proBNP below 400 fmol/ml. 83.3% of children in mild CHF group had their plasma NT-proBNP between (400-1400) fmol/ml while in moderate and severe CHF group 84.6% of children had their plasma NT-proBNP beyond 1400 fmol/ml. Plasma NT-proBNP was also positively correlated with LVEDVI and LVSEWS. There was no correlation among mVcFc, LVEF, LVFS, Con and plasma NT-proBNP concentration. Using plasma NT-proBNP concentration > or = 400 fmol/ml as cut-point for diagnosing CHF, the sensitivity was 89.3%, the specificity was 91.2%, and the area under the ROC curve was 0.944.</p><p><b>CONCLUSIONS</b>Plasma NT-proBNP level could be used to assess cardiac function and diagnose CHF in pediatric patients with VSD.</p>

Evaluation of diagnostic criteria for infective endocarditis:an analysis of 216 pathologically proven patients / 中华儿科杂志

<p><b>OBJECTIVE</b>Eighteen to twenty-four percent of patients with infective endocarditis (IE) proved pathologically were clinically possible IE by the Duke criteria. In order to improve the sensitivity, the new criteria (trial) for the diagnosis of IE was proposed by Pediatric Cardiology Association of China and Editorial Committee of Chinese Journal of Pediatrics. The aim of this study was to evaluate and compare the value of the new criteria (trial) for the diagnosis of IE with the Duke criteria.</p><p><b>METHODS</b>Group A consisted of 193 patients proved with IE at autopsy or surgery, where the cases had the results of blood culture and echocardiography data, and Group B had 23 patients with clinical diagnosis of IE in whom evidence of IE was not found at surgery. All the above cases were collected from 15 hospitals. They were analyzed and classified by the new criteria and at the same time by the Duke criteria. The sensitivity and specificity of both criteria for the diagnosis of IE were compared.</p><p><b>RESULTS</b>(1) In Group A, same microorganisms were detected twice in blood culture in 50 patients (25.9%), while 36 patients (18.7%) had only one positive blood culture. Endocardial involvement was found by echocardiography in 165 cases (85.5%), including vegetation in 160 (82.9%), perforation of aortic valve in 4 (2.1%), and partial dehiscence of ventricular septal defect (VSD) patch in one (0.5%). Vegetation appeared oscillating masses in 100 cases (62.5%). One hundred and eighty (93.3%) patients had predisposing heart conditions, and 151 (72.8%) with congenital heart diseases. Fever was revealed in 178 cases (92.2%). Vegetation or perforation of aortic valve was detected in all patients without fever. Heart failure was complicated in 91 patients, 7 of whom had no fever. Vascular phenomena including petechiae and major arterial emboli occurred in 21 and 28 cases, respectively. Among immunologic phenomena, glomerulonephritis occurred in 9, elevated rheumatoid factor in 17/25 and elevated CRP in 51/71. In Group B, the same microorganism was detected in blood culture twice in only 3 patients and 2 patients had one positive blood culture. Vegetation in tricuspid valve was found by echocardiography in one patient. (2) Ninety-four cases (48.7%) of Group A were clinically confirmed IE by the Duke criteria. The diagnosis was made on the basis of two major criteria in 42, one major and 3 minor criteria in 52.14 of 99 as possible IE were excluded by the modified Duke criteria. On the other hand, a definite diagnosis of IE was made in 156 patients (80.8%) by the new criteria. Of them, 94 met with definite criteria of the Duke criteria, 62 (32%) met with echocardiographic evidence of endocardial involvement (major criteria) and two minor criteria. No patient of Group B was clinically definite with the Duke criteria, but one patient was clinically definite with the new criteria (trial). (3) The sensitivity and specificity for the diagnosis of IE were 80.8% and 95.7%, respectively, with the new criteria (trial), 48.7% and 100%, respectively, with the Duke criteria.</p><p><b>CONCLUSION</b>With the addition of echocardiographic evidence of endocardial involvement (major criteria) and 2 minor criteria as definite diagnostic criteria, the sensitivity of the new criteria (trial) is superior to that of the Duke criteria, but there is no significant difference in specificity for the diagnosis of IE between the two criteria.</p>