Digoxin for the treatment of fetal congestive heart failure with sinus rhythm assessed by cardiovascular profile score.

OBJECTIVE: To evaluate the effects of digoxin on the progression of congestive heart failure (CHF), and to determine the best predictors of perinatal death in fetuses with sinus rhythm and CHF. METHODS: This was a retrospective case series of fetuses with CHF treated with transplacental digoxin, evaluated at baseline (before treatment), weekly during treatment, and prior to death or delivery, using a 10-point cardiovascular profile score (CVPS) consisting of echocardiographic markers of cardiac dysfunction: cardiomegaly, valve insufficiency, hydrops, and abnormal venous and arterial Doppler flow profiles. Composite CVPS and component markers were compared before and after digoxin treatment by nonparametric testing and best predictors of perinatal survival assessed by regression analysis and receiver operating characteristics. RESULTS: The overall mortality of the 28 subjects was 32%. First, last, and CVPS after 1 week of treatment predicted survival (odds ratio 2.34, 95% confidence interval 1.10-4.96) with a CVPS of > or=6 being the best predictor of survival (sensitivity 0.83, specificity 0.75). All fetuses that died had notching of the umbilical venous flow. CVPS increased from baseline during treatment (p = 0.003) in all subjects. CONCLUSIONS: The CVPS score is useful in assessing therapeutic effects of digoxin in the fetus with multiple etiologies for CHF. Further studies are needed to test the efficacy of digoxin in specific defects causing CHF.

Update in fetal cardiac intervention.

The severity of fetal heart disease progresses during gestation and may lead to significant in utero or postnatal morbidity and mortality. Fetal echocardiography allows us to detect heart disease early enough in pregnancy to perform fetal cardiac intervention that may change the natural history of some diseases. The principal aims are the prevention of hydrops due to congenital heart disease, recruitment of hypoplastic ventricles, remodeling of the fetal pulmonary vascular bed, or creation of a two-ventricular circulation after birth without risk to the mother. The initial fetal interventions for valvuloplasty and atrial septostomy showed a high mortality and did not achieve significant change in the final outcome of patients. Nevertheless, some technique modifications have improved the outcome of these patients, making fetal cardiac intervention a promising treatment for congenital heart disease. Conversely, different assessment tools for selection of the correct patient have been studied in some series to improve the success of these procedures and thus the survival odds. We believe that percutaneous procedures with local anesthesia are preferable.

Cirugía de Fontan: Factores de riesgo a corto y mediano plazo / Fontan operation: factors influencing early and late outcomes

Se presenta un análisis retrospectivo de pacientes sometidos a cirugía de Fontan, de enero de 1989 a diciembre 2003, con el fin de evaluar los resultados, así como las variables clínicas y hemodinámicas que inciden en su morbilidad y mortalidad. Se estudiaron un total de 81 pacientes con los siguientes diagnósticos: 53 con atresia tricuspídea, 14 con atresia pulmonar con septum intacto, 11 con conexión atriouniventricular y 3 con anomalía de Ebstein. A 61 pacientes se les realizó Fontan con túnel intra-atrial y en 20 se utilizó un tubo extracardíaco, fenestrados en 53 pacientes. La mortalidad operatoria (< 30 días) fue 13% para atresia tricuspídea y 25% en el resto, siendo básicamente ésta por choque cardiogénico y arritmias graves. La sobrevida global fue de 71% en 55 meses de seguimiento. Hubo que desmantelar el Fontan en 5 casos. De las diversas variables analizadas se encontró 2.8 veces más riesgo de morir en pacientes sin fenestración y 3.6 veces cuando a las 72 hrs postquirúrgicas la presión de atrio izquierdo fue > 10 mmHg y la presión media de la arteria pulmonar > 20 mmHg. Las complicaciones más relevantes fueron: arritmias (38%), enteropatía perdedora de proteínas (8%) y eventos trombóticos cerebrales (1 %). El 52% de los pacientes han reingresado siendo las principales causas falla hemodinámica e infecciones.

The purpose of this retrospective study was to determine the outcome of patients who underwent a Fontan procedure at National Heart Institute "Ignacio Chavez", Mexico, from January 1989 to December 2003. We had 81 patients with a mean age of 7 years old: 53 with tricuspid atresia, 14 with pulmonary atresia and intact septum, 11 with univentricular atrioventricular connection and 3 with Ebstein's anomaly. An intra-atrial tunnel was performed on 61 patients and an extracardiac conduit on the rest. Of all, 53 underwent a fenestration. The surgical mortality was 13% fortricuspid atresia and 25% for the other diseases. We had an overall mortality of 28.4%, being the main causes cardiogenic shock and arrhythmia. The global survival was 71% in 55 months of following. Takedown was indicated on 5 patients. The patients without fenestration showed to have 2.8 times more risk of death. The mean pulmonary artery pressure > 20 mm Hg plus the left atrium pressure > 10 mmHg increased the death risk 3.6 times. Of the 52% who required readmission, the main causes were hemodynamical failure and infections. The more relevant complications were: arrhythmia (38%), protein-losing enteropathy (8%) and thrombotic cerebral events (1.4%).

[Fontan operation: short- and long-term risk factors]. / Cirugía de Fontan. Factores de riesgo a corto y mediano plazo.

The purpose of this retrospective study was to determine the outcome of patients who underwent a Fontan procedure at National Heart Institute "Ignacio Chávez", Mexico, from January 1989 to December 2003. We had 81 patients with a mean age of 7 years old: 53 with tricuspid atresia, 14 with pulmonary atresia and intact septum, 11 with univentricular atrioventricular connection and 3 with Ebstein's anomaly. An intra-atrial tunnel was performed on 61 patients and an extracardiac conduit on the rest. Of all, 53 underwent a fenestration. The surgical mortality was 13% for tricuspid atresia and 25% for the other diseases. We had an overall mortality of 28.4%, being the main causes cardiogenic shock and arrhythmia. The global survival was 71% in 55 months of following. Takedown was indicated on 5 patients. The patients without fenestration showed to have 2.8 times more risk of death. The mean pulmonary artery pressure > or = 20 mmHg plus the left atrium pressure > or = 10 mmHg increased the death risk 3.6 times. Of the 52% who required readmission, the main causes were hemodynamical failure and infections. The more relevant complications were: arrhythmia (38%), protein-losing enteropathy (8%) and thrombotic cerebral events (1.4%).