[Surgical strategies in Ebstein anomaly: 28 years' experience in a pediatric hospital]. / Estrategias y avances quirúrgicos en la anomalía Ebstein: 28 años de experiencia en un hospital pediátrico.

Objectives: Ebstein anomaly is a congenital defect characterized by a lack of delamination and apical displacement of the tricuspid valve, tricuspid insufficiency, right atrial enlargement, and ventricular dysfunction. To analyze the results and evolution of the different surgical strategies, data were collected from 45 patients operated on during 1990-2018. Twenty-six patients were included with a median age at initial surgery of 11.3 years (range: 13 days-18.6 years). Method: Procedures were plastic 10 patients (38%), cone technique reconstruction 11 (42%), and replacement 5 (19%). Additional interventions were required in 7 patients: cavo-pulmonary anastomosis 4 and Cox-maze 4. Nine patients (34.6%) required reoperation due to severe tricuspid insufficiency. Six had previous plastic, two bioprothesis, and one, cone. Results: Overall mortality was 11.5% (3)at a median of 10.1 years post-surgery (range: 5.7-10.12) associated with arrhythmias (p = 0.05), right (p = 0.008), left (p = 0.0001) ventricular dysfunction and reoperations (p = 0.03). None were previous conus. Median follow-up was 6.5 years (range: 1-29.1). Ninety-one-point-six percent were in functional class I/II and 79.2% in sinus rhythm. Conclusions: The results of the different classic techniques were similar, although not free of complications and reoperations. Cone reconstruction proved to be effective, with low surgical mortality, less need for reoperations, and durability in the medium term.

Objetivos: La anomalía de Ebstein es un defecto congénito caracterizado por falta de deslaminación y desplazamiento apical de la válvula tricúspide, insuficiencia tricúspidea, agrandamiento auricular derecho y disfunción ventricular. Con el propósito de analizar los resultados y evolución de las distintas estrategias quirúrgicas se recolectaron datos de 45 operados durante 1990-2018. Se incluyeron 26 pacientes con una edad mediana en la cirugía inicial de 11.3 años (rango: 13 días-18.6 años). Método: Los procedimientos fueron plastia 10 pacientes (38%), reconstrucción con técnica del cono 11 (42%) y reemplazo 5 (19%). Requirieron intervenciones adicionales 7 pacientes: anastomosis cavo-pulmonar 4 y Cox-maze 4. El 34.6% (9) requirió reoperación por insuficiencia tricúspidea importante. Presentaban plastia previa seis, bioprótesis dos y cono, uno. Resultados: La mortalidad global fue del 11.5% (3 pacientes) a una media de 10.1 años posquirúrgicos (rango: 5.7-10.12) asociada a arritmias (p = 0.05), disfunción ventricular derecha (p = 0.008), izquierda (p = 0.0001) y reoperaciones (p = 0.03). Ninguno fue cono previo. La mediana de seguimiento fue de 6.5 años (rango: 1-29.1). El 91.6% se encontraban en clase funcional I/II y el 79.2% en ritmo sinusal. Conclusiones: Los resultados de las diferentes técnicas clásicas fueron similares aunque no exentas de complicaciones y reoperaciones. La reconstrucción del cono resultó ser efectiva, de baja mortalidad quirúrgica, menor requerimiento de reoperaciones y duradera en el mediano plazo.

[Pediatric telecardiology experience in the COVID-19 pandemic context]. / Experiencia en telecardiología infantil en el contexto de la pandemia de COVID-19.

Introduction: The COVID-19 pandemic has caused a global impact on public health services. Using new strategies through telehealth for the management of patients with congenital heart disease was the challenge. Objective: To describe the experience in telecardiology, and the strategies implemented during the pandemic. Method: Retrospective, qualitative study that includes the period from April 2020 to April 2021. Inquiries were received through the service's official e-mail or telephone. They were classified according to the type of concern and complexity of heart disease using color coding. The responses were asynchronous (by e-mail) or synchronous (videoconferences). The videoconferences were made using a secure platform (Cisco-Webex). Results: From April 2020 to April 2021, a total of 3372 queries were answered. The responses were distributed via e-mail (64.9%), phone calls (1.2%) and videoconferences (14.5%). The most frequent reasons for consultation were the request for missed appointments (68%), and remote clinical monitoring (20%). A total of 2296 families was contacted. Only 14.1% of the inquiries were cited in person. With color coding, a stratification was performed according to urgency. Conclusions: Telehealth proved to be a useful tool for the clinical management of patients with congenital heart disease in their place of origin. It prevented a considerable number of transfers, identified patients at risk rapidly, comforted families, and strengthened ties with local hospitals that make up the health network.

Introducción: La pandemia de COVID-19 ha causado un impacto global en los servicios de salud pública. Utilizar nuevas estrategias a través de la telesalud para el manejo de los pacientes con cardiopatías congénitas fue el desafío. Objetivo: Describir la experiencia en telecardiología y las estrategias implementadas durante la pandemia. Método: Estudio retrospectivo, cualitativo, que comprende el periodo de abril de 2020 a abril de 2021. Se recibieron consultas a través del correo electrónico oficial del servicio o por teléfono. Se clasificaron según tipo de inquietud y complejidad de la cardiopatía utilizando una codificación por colores. Las respuestas a las mismas fueron asincrónicas (correo electrónico) o sincrónicas (videoconferencias). Las videoconferencias se realizaron utilizando una plataforma segura (Cisco-Webex). Resultados: Se contestaron 3372 consultas. Las respuestas fueron distribuidas en correos electrónicos (64.9%), llamados telefónicos (1.2%), videoconferencias (14.5%) y otros métodos (19.4%) Los motivos de consulta más frecuentes fueron la solicitud de turnos suspendidos (68%) y control clínico a distancia (20%). Se pudo establecer contacto con 2296 familias. Solo el 14.1% de las consultas se citó en forma presencial. Con la codificación por colores se logró realizar una estratificación según la urgencia. Conclusiones: La telesalud mostró ser una herramienta útil para el manejo clínico de pacientes con cardiopatías congénitas en su lugar de origen. Evitó un gran número de traslados, identificó pacientes en riesgo, confortó a las familias y fortaleció vínculos con hospitales locales que integran la red de salud.

Inmunización con vacunas ARN mensajero contra la COVID-19 en pacientes adolescentes con antecedente de síndrome inflamatorio multisistémico: serie de casos / Immunization with messenger RNA vaccines against COVID-19 in adolescents with a history of multisystem inflammatory

Los niños cursan mayormente la infección por el virus SARS-CoV-2 en forma leve. Sin embargo, de forma muy infrecuente algunos pueden desarrollar una patología con marcada gravedad denominada síndrome inflamatorio multisistémico en niños relacionado temporalmente con COVID-19 (SIM-C). Dado su reciente surgimiento, aún hay aspectos de su fisiopatología que se desconocen. La posibilidad de recidiva en caso de reinfección o ante la vacunación contra SARS-CoV-2 son nuevos interrogantes a los que nos enfrentamos. Reportamos una serie de casos de 4 pacientes adolescentes que cursaron SIM-C y meses después han sido vacunados contra SARS-CoV-2 con plataformas ARN mensajero (ARNm) sin presentar recurrencia de la enfermedad ni efectos adversos cardiológicos

In most cases, children with SARS-CoV-2 have a mild infection. However, very rarely, some children may develop a severe disease called multisystem inflammatory syndrome in children temporally associated with COVID-19 (MIS-C). Given its recent emergence, some aspects of its pathophysiology are still unknown. The possibility of recurrence in case of reinfection or SARS-CoV-2 vaccination are new questions we are facing. Here we report a case series of 4 adolescent patients who developed MIS-C and, months later, received the SARS-CoV-2 vaccine with messenger RNA (mRNA) platforms without disease recurrence or cardiac adverse events.

Immunization with messenger RNA vaccines against COVID-19 in adolescents with a history of multisystem inflammatory syndrome: a case series. / Inmunización con vacunas ARN mensajero contra la COVID-19 en pacientes adolescentes con antecedente de síndrome inflamatorio multisistémico: serie de casos.

In most cases, children with SARS-CoV-2 have a mild infection. However, very rarely, some children may develop a severe disease called multisystem inflammatory syndrome in children temporally associated with COVID-19 (MIS-C). Given its recent emergence, some aspects of its pathophysiology are still unknown. The possibility of recurrence in case of reinfection or SARS-CoV-2 vaccination are new questions we are facing. Here we report a case series of 4 adolescent patients who developed MIS-C and, months later, received the SARS-CoV-2 vaccine with messenger RNA (mRNA) platforms without disease recurrence or cardiac adverse events.

Los niños cursan mayormente la infección por el virus SARS-CoV-2 en forma leve. Sin embargo, de forma muy infrecuente algunos pueden desarrollar una patología con marcada gravedad denominada síndrome inflamatorio multisistémico en niños relacionado temporalmente con COVID-19 (SIM-C). Dado su reciente surgimiento, aún hay aspectos de su fisiopatología que se desconocen. La posibilidad de recidiva en caso de reinfección o ante la vacunación contra SARS-CoV-2 son nuevos interrogantes a los que nos enfrentamos. Reportamos una serie de casos de 4 pacientes adolescentes que cursaron SIM-C y meses después han sido vacunados contra SARS-CoV-2 con plataformas ARN mensajero (ARNm) sin presentar recurrencia de la enfermedad ni efectos adversos cardiológicos.

Perception of family members and health professionals about institutional violence against hospitalized children.

OBJECTIVE: To understand the perception of family members and health professionals about institutional violence against hospitalized children. METHODS: Qualitative, exploratory-descriptive study, used approximations with Foucault's thinking, carried out in a pediatric unit of a large hospital in Salvador - Bahia. 10 mothers and 39 health professionals participated. Data collection took place between November/2018 and October/2019 through semi-structured interviews. Data content analysis was performed with the help of the NVIVO12 software. The study, approved by Ethics Committee, complied with resolution 466/2012. RESULTS: The Institutional Violence was understood by the participants evidenced in three categories: abusive care practices; problems in the relationships between professionals, child and family; precariousness of the hospital structure. CONCLUSION: The perception of family members and health professionals about the presence of Institutional Violence in children's hospital care demonstrates the need to establish actions in their confrontation to ensure the dignity of the child during hospitalization.

Congenitally corrected transposition of the great arteries outcomes of different surgical techniques in a paediatric population: A single-centre report.

BACKGROUND: Congenitally corrected transposition of the great arteries is a complex pathology characterised by atrioventricular and ventriculo-arterial discordance. Optimal surgical approaches are still a matter of debate. OBJECTIVE: To evaluate the outcomes of different surgical treatments in a single centre. METHODS: Between 1998 and 2020, 89 patients were studied. The cohort was divided into three groups: physiologic, anatomic, and univentricular repair. RESULT: Physiologic correction (56.18%) was associated with significant tricuspid valve regurgitation progress (42%) and complete AV block (30%) compared to anatomic repair. Right ventricular systolic dysfunction was developed in 14%. Instead, anatomic correction (30.34%) (double switch 59% and Rastelli type 40.7%) presented moderate to severe aortic regurgitation (4%) and left ventricular systolic dysfunction (11%). Complete AV block was developed in 14.8%. Rate of reintervention was 34% for physiologic and 26% for anatomic. Univentricular palliation (13.8%) presented no complications or late mortality during the follow-up. The overall survival at 5 and 10 years, respectively, was 80% (95% CI 69, 87) and 75% (95% CI 62, 84). There was no statistically significant difference in mortality between the groups (p log-rank = 0.5752). CONCLUSION: Management of congenitally corrected transposition of the great arteries remains a challenge. In this cohort, outcomes after physiologic repair were satisfactory in spite of the progression of tricuspid regurgitation and the high incidence of AV block. Anatomic repair improved tricuspid regurgitation but increased the risk of aortic regurgitation and left ventricular systolic dysfunction. The Fontan group showed the lowest incidence of complications.

Perception of family members and health professionals about institutional violence against hospitalized children / Percepción de familiares y profesionales de la salud sobre la violencia institucional a niños hospitalizados / Percepção de familiares e profissionais de saúde sobre a violência institucional à criança hospitalizada

ABSTRACT Objective: To understand the perception of family members and health professionals about institutional violence against hospitalized children. Methods: Qualitative, exploratory-descriptive study, used approximations with Foucault's thinking, carried out in a pediatric unit of a large hospital in Salvador - Bahia. 10 mothers and 39 health professionals participated. Data collection took place between November/2018 and October/2019 through semi-structured interviews. Data content analysis was performed with the help of the NVIVO12 software. The study, approved by Ethics Committee, complied with resolution 466/2012. Results: The Institutional Violence was understood by the participants evidenced in three categories: abusive care practices; problems in the relationships between professionals, child and family; precariousness of the hospital structure. Conclusion: The perception of family members and health professionals about the presence of Institutional Violence in children's hospital care demonstrates the need to establish actions in their confrontation to ensure the dignity of the child during hospitalization.

RESUMEN Objetivo: Comprender la percepción de familiares y profesionales de la salud sobre la violencia institucional contra los niños hospitalizados. Métodos: estudio cualitativo, exploratorio-descriptivo, que utilizó aproximaciones con el pensamiento de Foucault, realizado en una unidad de pediatría de un gran hospital de Salvador - Bahía. Participaron 10 madres y 39 profesionales de la salud. La recolección de datos se realizó entre noviembre / 2018 y octubre / 2019 a través de entrevistas semiestructuradas. Data content analysis was performed with the help of the software NVIVO12. El estudio, aprobado por el Comité de Ética, cumplió con la resolución 466/2012. Resultados: El Violencia Institucional fue entendido por los participantes evidenciado en tres categorías: prácticas de cuidado abusivo; problemas en las relaciones entre profesionales, niño y familia; precariedad de la estructura hospitalaria. Conclusión: La percepción de familiares y profesionales de la salud sobre la presencia de Violencia Institucional en la atención hospitalaria infantil demuestra la necesidad de establecer acciones en su enfrentamiento para asegurar la dignidad del niño durante la hospitalización.

RESUMO Objetivo: Compreender a percepção de familiares e profissionais de saúde sobre a Violência Institucional à criança hospitalizada. Método: Estudo qualitativo, exploratório-descritivo, de aproximações com o pensamento foucaultiano, realizado em unidade pediátrica de hospital de grande porte em Salvador/Bahia. Participaram 10 mães e 39 profissionais de saúde. A coleta de dados ocorreu entre novembro/2018 e outubro/2019 através de entrevista semiestruturada. Foi realizada análise de conteúdo dos dados, com auxílio do software NVIVO12. O estudo foi aprovado por um comitê de ética e respeitou a Resolução 466/2012. Resultados: A Violência Institucional foi compreendida pelos participantes como: práticas de cuidado abusivas; problemas nas relações entre profissionais, criança e família; precarização da estrutura hospitalar. Conclusão: A percepção de familiares e profissionais de saúde sobre a presença da Violência Institucional no cuidado hospitalar infantil demonstra a necessidade de estabelecer ações para o seu enfrentamento para assegurar a dignidade da criança durante a hospitalização.

Langmuir-Blodgett monolayers holding a wound healing active compound and its effect in cell culture. A model for the study of surface mediated drug delivery systems.

Langmuir and Langmuir-Blodgett films holding a synthetic bioinspired wound healing active compound were used as drug-delivery platforms. Palmitic acid Langmuir monolayers were able to incorporate 2-methyltriclisine, a synthetic Triclisine derivative that showed wound healing activity. The layers proved to be stable and the nanocomposites were transferred to solid substrates. Normal human lung cells (Medical Research Council cell strain 5, MRC-5) were grown over the monomolecular Langmuir-Blodgett films that acted as a drug reservoir and delivery system. The proliferation and migration of the cells were clearly affected by the presence of 2-methyltriclisine in the amphiphilic layers. The methodology is proposed as a simple and reliable model for the study of the effects of bioactive compounds over cellular cultures.

Formation of dendrimer-guest complexes as a strategy to increase the solubility of a phenazine N, N'-dioxide derivative with antitumor activity.

Poly(amidoamine) and Poly(propylenimine) dendrimers with different generations and peripheral groups were studied as solubility enhancers and nanocarriers for 7-bromo-2-hydroxy-phenazine N 5,N 10-dioxide. This compound possesses potential antitumoral and anti-trypanosomal activity, but its low solubility in physiological media precludes its possible application as therapeutic drug. The amino terminated dendrimers association with the active compounds as observed trough NMR studies showed that electrostatic interactions are essential in the solubilization enhancement process. The obtaining of a stable and no cytotoxic formulation makes the drug-carried association a suitable strategy for the generation of a drug delivery system for phenazine derivatives.

Takayasu arteritis in paediatrics.

Takayasu arteritis is an idiopathic chronic granulomatous panarteritis predominantly affecting the aorta and its main branches. Although idiopathic, genetic contribution to disease susceptibility is being increasingly recognised. Rare in children, Takayasu arteritis is a worldwide disease with significant morbidity and mortality. Its diagnosis is a challenge and requires awareness of the condition as clinical features at presentation are non-specific and assessing disease activity is difficult. In the inflammatory stage, treatment is essential to prevent the insidious course and vascular damage: stenotic, occlusive lesions, aneurysms, and aortic regurgitation. New imaging modalities, such as CT scan, MRI, and 18F-fluorodeoxyglucose positron emission tomography, have expanded the possibilities for non-invasive diagnosis and monitoring; however, digital subtraction arteriography remains the gold standard for the diagnosis of Takayasu arteritis. Steroids are the first-line medical treatment. The combined use of methotrexate, cyclophosphamide, azathioprine, mycophenolate mofetil, and biological agents is common. Revascularisation therapy should be considered in uncontrolled hypertension secondary to renal artery stenosis, symptomatic coronary ischaemia, cerebrovascular disease, severe aortic regurgitation, limb ischaemia, and aneurysms at risk of rupture, using surgical or endovascular procedures and taking into consideration that complications, especially restenosis, are frequent. Disease activity increases the likelihood of complications after revascularisation. Surgical intervention has shown better long-term outcomes, although the endovascular approach is evolving. The aim of this review was to describe key points of the diagnosis, treatment, and follow-up of Takayasu arteritis in childhood.

Endocarditis por Streptococcus pneumoniae en pediatría. Presentación de un caso clínico / Streptococcus pneumoniae endocarditis in a child: a case report

Resumen Introducción: la incidencia de infecciones invasivas por neumococo ha disminuido desde la genera lización de la vacuna neumocóccica conjugada, aunque el neumococo continúa siendo un patógeno prevalente en niños. De las infecciones invasivas por neumococo, la EI (endocarditis infecciosa) es una forma de presentación rara con una incidencia de 1 a 7%. Caso clínico: Presentamos el caso de un niño de 4 años previamente sano, con una única dosis de vacuna 10 valente conjugada para neu mococo, que consulta con fiebre, la aparición de un nuevo soplo cardíaco e insuficiencia cardíaca. Presentó desarrollo de S. pneumoniae en hemocultivos, sensible a penicilina. En el ecocardiograma transtorácico se observaron vegetaciones en válvula tricuspídea y pulmonar. Recibió 4 semanas de tratamiento antibiótico con diagnóstico de EI por neumococo. Evolucionó con daño valvular secun dario que requirió tratamiento quirúrgico. Conclusiones: Debe considerarse la EI como diagnóstico diferencial ante todo niño febril con la aparición de un nuevo soplo cardíaco, y al neumococo agente etiológico en los pacientes febriles con infecciones graves provenientes de la comunidad.

Abstract Introduction: the incidence of invasive infections caused by pneumococcus (Streptococcus pneumoniae) has declined since generalized vaccination with pneumococcal conjugated vaccine, but it is still a prevalent pathogen in children. Amongst pneumococcal invasive infections, IE (infectious endocarditis) is rare, with an incidence between 1 and 7%. Case report: We describe the case of a previously healthy 4 year old boy, who had received one dose of 10-valent pneumococcal conjugate vaccine who presents with fever, a new heart murmur and heart failure. Blood cultures were posi tive for penicillin susceptible pneumococcus. The transthoracic echocardiogram showed tricuspid and pulmonary valve vegetations. The patient received 4 weeks of antibiotic treatment for pneumo-coccal IE. He presented secondary valve damage that needed surgical treatment. Conclusions: IE should be considered as a differential diagnosis of children presenting with fever and a newly diag nosed heart murmur, and pneumococcus as an etiologic agent in non hospitalized febrile patients with severe infections.

Formation and characterization of Langmuir and Langmuir-Blodgett films of Newkome-type dendrons in presence and absence of a therapeutic compound, for the development of surface mediated drug delivery systems.

Organic macromolecules with dendrimeric architectures are polymeric materials potentially useful as nanocarriers for therapeutic drugs. In this work, we evaluate a series of Newkome-type dendrons in Langmuir and Langmuir-Blodgett films as platforms capable of interacting with a potential antitumoral agent. The nanocomposite is proposed as model for the development of surface mediated drug delivery systems. We were successful in the formation and characterization of pure (dendrons) and composite (drug-dendron) stable and reproducible monolayers, and their transfer to solid substrates. A detailed study of topographic characteristics of the generated surfaces by atomic force microscopy was conducted. Furthermore, we probed dendron monolayer films as anchorage surfaces for mammalian cells. Normal cell attachment and proliferation on the surfaces were observed. No evident cytotoxic effects were detected, demonstrating the adequate biocompatibility of the surfaces.

[Streptococcus pneumoniae endocarditis in a child: a case report]. / Endocarditis por Streptococcus pneumoniae en pediatría. Presentación de un caso clínico.

INTRODUCTION: the incidence of invasive infections caused by pneumococcus (Streptococcus pneumoniae) has declined since generalized vaccination with pneumococcal conjugated vaccine, but it is still a prevalent pathogen in children. Amongst pneumococcal invasive infections, IE (infectious endocarditis) is rare, with an incidence between 1 and 7%. CASE REPORT: We describe the case of a previously healthy 4 year old boy, who had received one dose of 10-valent pneumococcal conjugate vaccine who presents with fever, a new heart murmur and heart failure. Blood cultures were posi tive for penicillin susceptible pneumococcus. The transthoracic echocardiogram showed tricuspid and pulmonary valve vegetations. The patient received 4 weeks of antibiotic treatment for pneumo-coccal IE. He presented secondary valve damage that needed surgical treatment. CONCLUSIONS: IE should be considered as a differential diagnosis of children presenting with fever and a newly diag nosed heart murmur, and pneumococcus as an etiologic agent in non hospitalized febrile patients with severe infections.

Tratamiento endovascular en arteritis de Takayasu: Presentación de un caso clínico / Endovascular intervention in Takayasu Arteritis: Case report

Una paciente de cuatro años concurrió a la Guardia por edemas e hipertensión arterial. Al momento del examen físico, se detectó disminución del pulso en el brazo izquierdo y ausente en los miembros inferiores, con diferencia de tensión arterial mayor de 10 mmHg entre los miembros superiores. Se realizó un ecocardiograma, en el que se observó coartación grave de la aorta a nivel abdominal y disfunción ventricular. Con la sospecha de arteritis de Takayasu, se completaron estudios con angiotomografía cardíaca, que confirmó una desconexión de la arteria subclavia izquierda y estrechez grave en la aorta abdominal. El diagnóstico definitivo fue de arteritis de Takayasu. Se realizó una angioplastía con estent por Hemodinamia en la aorta abdominal, con buenos resultados posteriores. Mejoraron los pulsos de los miembros inferiores, y se obtuvieron valores normales de la tensión arterial. En el ecocardiograma, mejoró la función ventricular, y el gradiente en la zona de coartación se redujo significativamente.

A four year old patient with no medical history was admitted to our hospital's Emergency Department, suffering from edema and hypertension. During physical examination a low pulse was detected in the left arm and a lack of pulses in lower limbs, with a blood pressure difference greater than 10 mm Hg between both arms. An echocardiogram demonstrated severe aortic abdominal coarctation and ventricular dysfunction. Takayasu arteritis was diagnosed and cardiac angiography was performed. Disconnection of left subclavian artery and severe tightness at the abdominal aorta were confirmed. The definitive diagnosis was Takayasu arteritis. Angioplasty with stent was performed in abdominal aorta, with good subsequent results. The pulses improved in the lower limbs, and normal blood pressure values without gradient between all members were registered. The echocardiogram improved ventricular function and the gradient in the coarctation area was significantly reduced.

[Endovascular intervention in Takayasu Arteritis. Case report]. / Tratamiento endovascular en arteritis de Takayasu. Presentación de un caso clínico.

A four year old patient with no medical history was admitted to our hospital's Emergency Department, suffering from edema and hypertension. During physical examination a low pulse was detected in the left arm and a lack of pulses in lower limbs, with a blood pressure difference greater than 10 mm Hg between both arms. An echocardiogram demonstrated severe aortic abdominal coarctation and ventricular dysfunction. Takayasu arteritis was diagnosed and cardiac angiography was performed. Disconnection of left subclavian artery and severe tightness at the abdominal aorta were confirmed. The definitive diagnosis was Takayasu arteritis. Angioplasty with stent was performed in abdominal aorta, with good subsequent results. The pulses improved in the lower limbs, and normal blood pressure values without gradient between all members were registered. The echocardiogram improved ventricular function and the gradient in the coarctation area was significantly reduced.

Una paciente de cuatro años concurrió a la Guardia por edemas e hipertensión arterial. Al momento del examen físico, se detectó disminución del pulso en el brazo izquierdo y ausente en los miembros inferiores, con diferencia de tensión arterial mayor de 10 mmHg entre los miembros superiores. Se realizó un ecocardiograma, en el que se observó coartación grave de la aorta a nivel abdominal y disfunción ventricular. Con la sospecha de arteritis de Takayasu, se completaron estudios con angiotomografía cardíaca, que confirmó una desconexión de la arteria subclavia izquierda y estrechez grave en la aorta abdominal. El diagnóstico definitivo fue de arteritis de Takayasu. Se realizó una angioplastía con estent por Hemodinamia en la aorta abdominal, con buenos resultados posteriores. Mejoraron los pulsos de los miembros inferiores, y se obtuvieron valores normales de la tensión arterial. En el ecocardiograma, mejoró la función ventricular, y el gradiente en la zona de coartación se redujo significativamente.

Unique combination of atrioventricular septal defect with cor triatriatum and complete vascular ring.

Atrioventricular septal defect can present with one or more associated anomalies. Cor triatriatum (subdivided left atrium) and vascular rings are among the less frequent. We describe a two-month-old patient with these three cardiovascular anomalies. This case highlights the importance of exhaustive preoperative evaluation in order to achieve successful surgical correction in one stage.

Art Therapy: An Underutilized, yet Effective Tool.

Art therapy has been recognized as beneficial and effective since first described by Adrian Hill in 1942. Even before this time, art therapy was utilized for moral reinforcement and psychoanalysis. Art therapy aids patients with, but not limited to, chronic illness, physical challenges, and cancer in both pediatric and adult scenarios. Although effective in patient care, the practice of art therapy is extremely underutilized, especially in suburban areas. While conducting our own study in northeastern Ohio, USA, we found that only one out of the five inpatient institutions in the suburban area of Mahoning County, Ohio, that we contacted provided continuous art therapy to it's patients. In the metropolitan area of Cuyahoga County, Ohio, only eight of the twenty-two inpatient institutions in the area provided art therapy. There could be many reasons as to why art therapy is not frequently used in these areas, and medical institutions in general. The cause of this could be the amount of research done on the practice. Although difficult to conduct formal research on such a broad field, the American Art Therapy Association has succeeded in doing such, with studies showing improvement of the patient groups emotionally and mentally in many case types.

Bypass total del ventrículo pulmonar: complicaciones y sobrevida en el seguimiento alejado / Total Right Heart Bypass: Long-Term Complications and Survival

Introducción La cirugía de bypass total del ventrículo pulmonar (BPTVP) es un procedimiento paliativo con una incidencia elevada de complicaciones. El reconocimiento e individualización precoz de estas complicaciones es esencial para definir estrategias terapéuticas adecuadas. Objetivo Evaluar los eventos alejados del BPTVP, analizar la mortalidad alejada y comparar la técnica auriculopulmonar (AP) con el conducto extracardíaco (CE). Material y métodos Entre 1987 y 2010 se analizaron 191 pacientes sometidos a BPTVP con un tiempo medio de seguimiento posquirúrgico (X) de 6,5 ± 5 años (1-20 años). Los pacientes se dividieron, de acuerdo con la variante quirúrgica, en grupo I: A P, 39 pacientes, X = 14 años y grupo II: CE, 152 pacientes, X = 4 años. Resultados El 57% de los pacientes (n = 116) presentaron las siguientes complicaciones: La mortalidad global alejada fue del 4,6% (n = 9). En el análisis univariado, la mortalidad estuvo asociada con disfunción ventricular (p = 0,0000), enteropatía perdedora de proteínas (p = 0,0000), aleteo auricular (p = 0,0012), reoperaciones (p = 0,0006), estenosis subaórtica (p = 0,0024), trombos (p = 0,01) y la técnica quirúrgica AP (p = 0,0004). En el estudio multivariado, la mortalidad estuvo relacionada con disfunción ventricular [OR 27,7 (4,64-165,24); p = 0,0003], técnica AP [OR 2,5 (16,2-105,9); p = 0,0036] y enteropatía perdedora de proteínas [OR 9,31 (1,53-56,66); p = 0,01]. Conclusiones - El BPTVP presentó eventos adversos en el 57% de los pacientes durante el seguimiento alejado. - La mortalidad alejada estuvo asociada con disfunción ventricular, aleteo auricular, enteropatía perdedora de proteínas, estenosis subaórtica, reoperaciones, trombos y técnica quirúrgica auriculopulmonar. - Los predictores de mortalidad fueron la disfunción ventricular, la enteropatía perdedora de proteínas y la técnica auriculopulmonar.

Introduction Total right heart bypass (RHB) is a palliative procedure with high incidence of complications. Early recognition and individualization of these complications is crucial to define adequate therapeutic strategies. Objective To evaluate the incidence of events and mortality of total RHB during long-term follow-up and compare the atriopulmonary (AP) technique with the extracardiac conduit (EC). Methods Between 1987 and 2010, 191 patients undergoing total RHB with a mean follow-up (X) of 6.5 ± 5 years (1-20 years) after surgery were analyzed. The patients were divided, according to the surgical approach, in group I: A P, 39 patients, X=14 years and group II: EC, 152 patients, X=4 years. Results The following complications were present in 57% (n = 116) of the patients: Global long-term mortality was 4.6% (n = 9). At univariate analysis, mortality was associated with ventricular dysfunction (p=0.0000), protein-losing enteropathy (p=0.0000), atrial flutter (p=0.0012), reoperations (p=0.0006), sub-aortic stenosis (p=0.0024), thrombosis (p =0.01) and AP technique (p=0.0004). Multivariate analysis revealed that mortality was associated with ventricular dysfunction [OR 27.7 (4.64-165.24); p = 0.0003], AP technique [OR 2.5 (16.2-105.9); p = 0.0036] and protein-losing enteropathy [OR 9.31 (1.53-56.66); p = 0.01]. Conclusions - Adverse events were present in 57% of patients undergoing total RHB during long-term follow-up. - Long-term mortality was associated with ventricular dysfunction, atrial flutter, protein-losing enteropathy, sub-aortic stenosis, reoperations, thrombosis and atriopulmonary technique. - Ventricular dysfunction, protein-losing enteropathy and atriopulmonary technique were predictors of mortality.

Bypass total del ventrículo pulmonar: complicaciones y sobrevida en el seguimiento alejado / Total Right Heart Bypass: Long-Term Complications and Survival

Introducción La cirugía de bypass total del ventrículo pulmonar (BPTVP) es un procedimiento paliativo con una incidencia elevada de complicaciones. El reconocimiento e individualización precoz de estas complicaciones es esencial para definir estrategias terapéuticas adecuadas. Objetivo Evaluar los eventos alejados del BPTVP, analizar la mortalidad alejada y comparar la técnica auriculopulmonar (AP) con el conducto extracardíaco (CE). Material y métodos Entre 1987 y 2010 se analizaron 191 pacientes sometidos a BPTVP con un tiempo medio de seguimiento posquirúrgico (X) de 6,5 ± 5 años (1-20 años). Los pacientes se dividieron, de acuerdo con la variante quirúrgica, en grupo I: A P, 39 pacientes, X = 14 años y grupo II: CE, 152 pacientes, X = 4 años. Resultados El 57% de los pacientes (n = 116) presentaron las siguientes complicaciones: La mortalidad global alejada fue del 4,6% (n = 9). En el análisis univariado, la mortalidad estuvo asociada con disfunción ventricular (p = 0,0000), enteropatía perdedora de proteínas (p = 0,0000), aleteo auricular (p = 0,0012), reoperaciones (p = 0,0006), estenosis subaórtica (p = 0,0024), trombos (p = 0,01) y la técnica quirúrgica AP (p = 0,0004). En el estudio multivariado, la mortalidad estuvo relacionada con disfunción ventricular [OR 27,7 (4,64-165,24); p = 0,0003], técnica AP [OR 2,5 (16,2-105,9); p = 0,0036] y enteropatía perdedora de proteínas [OR 9,31 (1,53-56,66); p = 0,01]. Conclusiones - El BPTVP presentó eventos adversos en el 57% de los pacientes durante el seguimiento alejado. - La mortalidad alejada estuvo asociada con disfunción ventricular, aleteo auricular, enteropatía perdedora de proteínas, estenosis subaórtica, reoperaciones, trombos y técnica quirúrgica auriculopulmonar. - Los predictores de mortalidad fueron la disfunción ventricular, la enteropatía perdedora de proteínas y la técnica auriculopulmonar.(AU)

Introduction Total right heart bypass (RHB) is a palliative procedure with high incidence of complications. Early recognition and individualization of these complications is crucial to define adequate therapeutic strategies. Objective To evaluate the incidence of events and mortality of total RHB during long-term follow-up and compare the atriopulmonary (AP) technique with the extracardiac conduit (EC). Methods Between 1987 and 2010, 191 patients undergoing total RHB with a mean follow-up (X) of 6.5 ± 5 years (1-20 years) after surgery were analyzed. The patients were divided, according to the surgical approach, in group I: A P, 39 patients, X=14 years and group II: EC, 152 patients, X=4 years. Results The following complications were present in 57% (n = 116) of the patients: Global long-term mortality was 4.6% (n = 9). At univariate analysis, mortality was associated with ventricular dysfunction (p=0.0000), protein-losing enteropathy (p=0.0000), atrial flutter (p=0.0012), reoperations (p=0.0006), sub-aortic stenosis (p=0.0024), thrombosis (p =0.01) and AP technique (p=0.0004). Multivariate analysis revealed that mortality was associated with ventricular dysfunction [OR 27.7 (4.64-165.24); p = 0.0003], AP technique [OR 2.5 (16.2-105.9); p = 0.0036] and protein-losing enteropathy [OR 9.31 (1.53-56.66); p = 0.01]. Conclusions - Adverse events were present in 57% of patients undergoing total RHB during long-term follow-up. - Long-term mortality was associated with ventricular dysfunction, atrial flutter, protein-losing enteropathy, sub-aortic stenosis, reoperations, thrombosis and atriopulmonary technique. - Ventricular dysfunction, protein-losing enteropathy and atriopulmonary technique were predictors of mortality.(AU)