Acute rheumatic fever and rheumatic heart disease--priorities in prevention, diagnosis and management. A report of the CSANZ Indigenous Cardiovascular Health Conference, Alice Springs 2011.

Three priority areas in the prevention, diagnosis and management of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) were identified and discussed in detail: 1. Echocardiography and screening/diagnosis of RHD ­ Given the existing uncertainty it remains premature to advocate for or to incorporate echocardiographic screening for RHD into Australian clinical practice. Further research is currently being undertaken to evaluate the potential for echocardiography screening. 2. Secondary prophylaxis ­ Secondary prophylaxis (long acting benzathine penicillin injections) must be seen as a priority. Systems-based approaches are necessary with a focus on the development and evaluation of primary health care-based or led strategies incorporating effective health information management systems. Better/novel systems of delivery of prophylactic medications should be investigated. 3. Management of advanced RHD ­ National centres of excellence for the diagnosis, assessment and surgical management of RHD are required. Early referral for surgical input is necessary with multidisciplinary care and team-based decision making that includes patient, family, and local health providers. There is a need for a national RHD surgical register and research strategy for the assessment, intervention and long-term outcome of surgery and other interventions for RHD.

A silver-alginate-coated dressing to reduce peripherally inserted central catheter (PICC) infections in NICU patients: a pilot randomized controlled trial.

OBJECTIVE: Our aim was to evaluate the safety of a silver-alginate-containing dressing to reduce peripherally inserted central catheter (PICC) infections in neonatal intensive care unit (NICU) patients. STUDY DESIGN: Patients were randomized 3:1 to receive a patch containing silver, alginate and maltodextrin or standard of care. Patches were placed under the regular transparent retention dressing at the PICC exit site at insertion and were replaced with every dressing change at least every 2 weeks until PICC discontinuation. All study infants were monitored for adverse skin reactions. RESULT: A total of 100 infants were followed up for 1922 person-days, including 75 subjects with 89 PICCs who received the patch. The median birth weight (1330 g) and median gestational age (30 weeks) was lower in the patch group when compared with the controls (P=0.001 and 0.005, respectively). Study patients received the patch with their PICC at a median age of 5 days; the patch stayed in place for a median of 13 days. We noted no adverse skin reactions and found no evidence that the patch alters the microbiology of PICC-associated infections. CONCLUSION: This pilot trial suggests that silver-alginate-coated dressings are skin safe and their inclusion in future trials aimed at reduction of PICC-associated bloodstream infections in the NICU should be considered.

Neonatal pulmonary hypertension--urea-cycle intermediates, nitric oxide production, and carbamoyl-phosphate synthetase function.

BACKGROUND: Endogenous production of nitric oxide is vital for the decrease in pulmonary vascular resistance that normally occurs after birth. The precursor of nitric oxide is arginine, a urea-cycle intermediate. We hypothesized that low concentrations of arginine would correlate with the presence of persistent pulmonary hypertension in newborns and that the supply of this precursor would be affected by a functional polymorphism (the substitution of asparagine for threonine at position 1405 [T1405N]) in carbamoyl-phosphate synthetase, which controls the rate-limiting step of the urea cycle. METHODS: Plasma concentrations of amino acids and genotypes of the carbamoyl-phosphate synthetase variants were determined in 65 near-term neonates with respiratory distress. Plasma nitric oxide metabolites were measured in a subgroup of 10 patients. The results in infants with pulmonary hypertension, as assessed by echocardiography, were compared with those in infants without pulmonary hypertension. The frequencies of the carbamoyl-phosphate synthetase genotypes in the study population were assessed for Hardy-Weinberg equilibrium. RESULTS: As compared with infants without pulmonary hypertension, infants with pulmonary hypertension had lower mean (+/-SD) plasma concentrations of arginine (20.2+/-8.8 vs. 39.8+/-17.0 micromol per liter, P<0.001) and nitric oxide metabolites (18.8+/-12.7 vs. 47.2+/-11.2 micromol per liter, P=0.05). As compared with the general population, the infants in the study had a significantly skewed distribution of the genotypes for the carbamoyl-phosphate synthetase variants at position 1405 (P<0.005). None of the infants with pulmonary hypertension were homozygous for the T1405N polymorphism. CONCLUSIONS: Infants with persistent pulmonary hypertension have low plasma concentrations of arginine and nitric oxide metabolites. The simultaneous presence of diminished concentrations of precursors and breakdown products suggests that inadequate production of nitric oxide is involved in the pathogenesis of neonatal pulmonary hypertension. Our preliminary observations suggest that the genetically predetermined capacity of the urea cycle--in particular, the efficiency of carbamoyl-phosphate synthetase--may contribute to the availability of precursors for nitric oxide synthesis.

In utero repair of myelomeningocele: a comparison of endoscopy and hysterotomy.

OBJECTIVE: To compare endoscopic coverage of myelomeningocele with a maternal split-thickness skin graft in utero to definitive neurosurgical closure through a hysterotomy. METHODS: Four fetuses with isolated myelomeningocele underwent endoscopic coverage of the defect with a maternal split-thickness skin graft in a CO(2) environment at 22-24 weeks' gestation. Subsequently, 4 fetuses underwent standard neurosurgical closure of their myelomeningoceles at 28-29 weeks' gestation. RESULTS: The mean operating time for the endoscopic procedures was 297 +/- 69 min. Two fetal losses occurred as a result of chorioamnionitis and placental abruption, respectively. A third baby delivered at 28 weeks' gestation after prolonged disruption of the membranes. The 2 survivors required standard closure of the myelomeningocele after delivery. The mean operating time for the hysterotomy procedures was 125 +/- 8 min. No mortality occurred, and all the infants delivered between 33 and 36 weeks with well-healed myelomeningocele scars. At present, the functional levels of all infants approximate the anatomical levels of the lesions. CONCLUSION: With current technology, in utero repair of congenital myelomeningocele through a hysterotomy appears to be technically superior to procedures performed endoscopically.

Fetal surgery for myelomeningocele and the incidence of shunt-dependent hydrocephalus.

CONTEXT: Intrauterine closure of exposed spinal cord tissue prevents secondary neurologic injury in animals with a surgically created spinal defect; however, whether in utero repair of myelomeningocele improves neurologic outcome in infants with spina bifida is not known. OBJECTIVE: To determine whether intrauterine repair of myelomeningocele improves patient outcomes compared with standard care. DESIGN: Single-institution, nonrandomized observational study conducted between January 1990 and February 1999. SETTING: Tertiary care medical center. PARTICIPANTS: A sample of 29 study patients with isolated fetal myelomeningocele referred for intrauterine repair that was performed between 24 and 30 gestational weeks and 23 controls matched to cases for diagnosis, level of lesion, practice parameters, and calendar time. All infants were followed up for a minimum of 6 months after delivery. MAIN OUTCOME MEASURES: Requirement for ventriculoperitoneal shunt placement, obstetrical complications, gestational age at delivery, and birth weight for study vs control subjects. RESULTS: The requirement for ventriculoperitoneal shunt placement for decompression of hydrocephalus was significantly decreased among study infants (59% vs 91%; P = .01). The median age at shunt placement was also older among study infants (50 vs 5 days; P = .006). This may be explained by the reduced incidence of hindbrain herniation among study infants (38% vs 95%; P<.001). Following hysterotomy, study patients had an increased risk of oligohydramnios (48% vs 4%; P = .001) and admission to the hospital for preterm uterine contractions (50% vs 9%; P = .002). The estimated gestational age at delivery was earlier for study patients (33.2 vs 37.0 weeks; P<.001), and the birth weight of study neonates was less (2171 vs 3075 g; P<.001). CONCLUSIONS: Our study suggests that intrauterine repair of myelomeningocele decreases the incidence of hindbrain herniation and shunt-dependent hydrocephalus in infants with spina bifida, but increases the incidence of premature delivery.

Inhaled nitric oxide in premature neonates with severe hypoxaemic respiratory failure: a randomised controlled trial.

BACKGROUND: Inhaled nitric oxide improves oxygenation and lessens the need for extracorporeal-membrane oxygenation in full-term neonates with hypoxaemic respiratory failure and persistent pulmonary hypertension, but potential adverse effects are intracranial haemorrhage and chronic lung disease. We investigated whether low-dose inhaled nitric oxide would improve survival in premature neonates with unresponsive severe hypoxaemic respiratory failure, and would not increase the frequency or severity of intracranial haemorrhage or chronic lung disease. METHODS: We did a double-blind, randomised controlled trial in 12 perinatal centres that provide tertiary care. 80 premature neonates (gestational age < or = 34 weeks) with severe hypoxaemic respiratory failure were randomly assigned inhaled nitric oxide (n=48) or no nitric oxide (n=32, controls). Our primary outcome was survival to discharge. Analysis was by intention to treat. We studied also the rate and severity of intracranial haemorrhage, pulmonary haemorrhage, duration of ventilation, and chronic lung disease at 36 weeks' postconceptional age. FINDINGS: The two groups did not differ for baseline characteristics or severity of disease. Inhaled nitric oxide improved oxygenation after 60 min (p=0.03). Survival at discharge was 52% in the inhaled-nitric-oxide group and 47% in controls (p=0.65). Causes of death were mainly related to extreme prematurity and were similar in the two groups. The two groups did not differ for adverse events or outcomes (intracranial haemorrhage grade 2-4, 28% inhaled nitric oxide and 33% control; pulmonary haemorrhage 13% and 9%; chronic lung disease 60% and 80%). INTERPRETATION: Low-dose inhaled nitric oxide improved oxygenation but did not improve survival in severely hypoxaemic premature neonates. Low-dose nitric oxide in the most critically ill premature neonates does not increase the risk of intracranial haemorrhage, and may decrease risk of chronic lung injury.

The decreasing incidence and severity of retinopathy of prematurity.

PURPOSE: We sought to determine whether the incidence of retinopathy of prematurity (ROP) at our institution has changed since the Cryo-ROP recruitment period 10 years ago. METHODS: We determined the incidences of threshold ROP, prethreshold ROP, less-than-prethreshold ROP, and no disease for each of 3 birth weight classes (<750 g, 750 to 999 g, and 1000 to 1250 g) of infants born between July 1, 1995, and June 30, 1996, and cared for in the Vanderbilt Neonatal Intensive Care Unit. We then compared these with the rates from our institution during the Cryo-ROP study recruitment period (January 1, 1986, to November 30, 1987). RESULTS: The current incidence and severity of ROP have decreased substantially overall and for each weight group compared with the 1986-87 incidence (P < .001, Cochran-Mantel-Haenszel test). The incidence of "any ROP" decreased by 27% for infants with birth weights less than 750 g, by 51% for infants 750 to 999 g, and by 71% for infants 1000 to 1250 g. The incidence of "prethreshold or greater ROP" decreased by 70% for the 750 to 999 g and 77% for the 1000 to 1250 g weight groups. Although the decrease in "prethreshold or greater ROP" was not as dramatic (25%) for the infants less than 750 g, only 1 infant (10%) progressed to threshold disease in this group, whereas 7 (47%) did in 1986-87. The incidence of threshold ROP decreased by 84% for infants less than 750 g and by 66% for infants 750 to 999 g. No infant with birthweight greater than 999 g progressed to threshold ROP. CONCLUSIONS: The incidence of all levels of ROP has decreased substantially for all infants with birth weights less than 1251 g at Vanderbilt University Medical Center during the past decade. Putative factors responsible for this decrease may include surfactant use, continuous pulse oximetry, aggressive use of antenatal steroids, and improved neonatal nutritional support.

Effect of intrauterine myelomeningocele repair on central nervous system structure and function.

BACKGROUND: It has been postulated that intrauterine myelomeningocele repair might improve neurologic outcome in patients with myelomeningocele. A total of 59 such procedures have been performed at Vanderbilt University. Preliminary results suggested that the degree of hindbrain herniation is reduced by intrauterine repair. In an attempt to further quantify the possible benefits of this surgery, a subset of these patients was brought back to Vanderbilt for study. METHODS: A group of 26 patients who had undergone intrauterine myelomeningocele repair underwent an extensive evaluation which included manual muscle testing, MR imaging and precise determination of the anatomic level of their lesions as well as multiple other tests. The results of this analysis were compared to those in 2 groups of historical controls. RESULTS: In this group of patients intrauterine myelomeningocele repair substantially reduced the incidence of moderate to severe hindbrain herniation (4 vs. 50%). The incidence of shunt-dependent hydrocephalus was more modestly reduced (58 vs. 92%). The average level of leg function closely matched the average anatomic level of the lesion in both the fetal surgery and control groups. CONCLUSION: The most dramatic effect of intrauterine repair appears to be on hindbrain herniation. A less dramatic, but significant, reduction in shunt-dependent hydrocephalus is also seen. Prospective patients should be cautioned not to expect improvement in leg function as the result of this surgery. The potential benefits of surgery must be carefully weighed against the potential risks of prematurity.

Subatmospheric oxygen therapy complicating subcutaneous emphysema.

An infant with hypoplastic left heart syndrome, excessive pulmonary blood flow, and tachypnea was placed on subatmospheric oxygen (supplemental nitrogen) to increase pulmonary vascular resistance and decrease pulmonary blood flow. His cardiorespiratory status stabilized without mechanical ventilation, but 2 weeks later he developed spontaneous subcutaneous emphysema. The emphysema worsened over approximately 1 month. During this time his left-to-right shunt gradually decreased, and he was weaned to room air. Even without the use of supplemental oxygen the emphysema resolved without complication, and the patient underwent successful orthotopic heart transplantation at 65 days of age.

Impact of an aggressive coronary stenting strategy on the incidence of target lesion revascularization.

Coronary stenting has been shown to reduce the incidence of target lesion revascularization (TLR) compared with balloon angioplasty in highly selected patients. However, the impact of an aggressive coronary stenting strategy in unselected patients on the overall incidence of TLR is unclear. We assessed the effect of increased stenting by comparing long-term results in consecutive patients who underwent successful percutaneous revascularization (with or without stents) during June to December 1995 (n=347) with those in June to December 1996 (n=401). Stents were used in 22.5% of patients in 1995 versus 66.1% in 1996 (p <0.0001). Mean age of the patients was 62+/-11 years (71% men) in 1995 versus 63+/-10 in 1996 (76% men) (p=NS). The 2 groups were well matched with the exception that the 1996 cohort included more patients with unstable coronary syndromes (25% in 1995 vs 34% in 1996 (p=0.003). There was no significant difference in the incidence of in-hospital adverse events. After 12 months of follow-up (complete in 95% of patients in each group), the incidence of TLR was significantly lower in the 1996 cohort than in the 1995 cohort (8.5% vs 14.7%, p=0.0075). This was mainly due to reduced requirement for repeat angioplasty in 1996 patients compared with 1995 (6.5% vs 11.8%, p=0.011). It is concluded that in an unselected patient population, an aggressive coronary stenting strategy was associated with a marked overall reduction in requirement for TLR over a 12-month period.

Randomized, multicenter trial of inhaled nitric oxide and high-frequency oscillatory ventilation in severe, persistent pulmonary hypertension of the newborn.

BACKGROUND: Although inhaled nitric oxide (iNO) causes selective pulmonary vasodilation and improves oxygenation in newborn infants with persistent pulmonary hypertension, its effects are variable. We hypothesized (1) that the response to iNO therapy is dependent on the primary disease associated with persistent pulmonary hypertension of the newborn (PPHN) and (2) that the combination of high-frequency oscillatory ventilation (HFOV) with iNO would be efficacious in patients for whom either therapy alone had failed. METHODS: To determine the relative roles of iNO and HFOV in the treatment of severe PPHN, we enrolled 205 neonates in a randomized, multicenter clinical trial. Patients were stratified by predominant disease category: respiratory distress syndrome (n = 70), meconium aspiration syndrome (n = 58), idiopathic PPHN or pulmonary hypoplasia (excluding congenital diaphragmatic hernia) ("other": n = 43), and congenital diaphragmatic hernia (n = 34); they were then randomly assigned to treatment with iNO and conventional ventilation or to HFOV without iNO. Treatment failure (partial pressure of arterial oxygen [PaO2] < 60 mm Hg) resulted in crossover to the alternative treatment; treatment failure after crossover led to combination treatment with HFOV plus iNO. Treatment response with the assigned therapy was defined as sustained PaO2 of 60 mm Hg or greater. RESULTS: Baseline oxygenation index and PaO2 were 48 +/- 2 and 41 +/- 1 mm Hg, respectively, during treatment with conventional ventilation. Ninety-eight patients were randomly assigned to initial treatment with HFOV, and 107 patients to iNO. Fifty-three patients (26%) recovered with the initially assigned therapy without crossover (30 with iNO [28%] and 23 with HFOV [23%]; p = 0.33). Within this group, survival was 100% and there were no differences in days of mechanical ventilation, air leak, or supplemental oxygen requirement at 28 days. Of patients whose initial treatment failed, crossover treatment with the alternate therapy was successful in 21% and 14% for iNO and HFOV, respectively (p = not significant). Of 125 patients in whom both treatment strategies failed, 32% responded to combination treatment with HFOV plus iNO. Overall, 123 patients (60%) responded to either treatment alone or combination therapy. By disease category, response rates for HFOV plus iNO in the group with respiratory syndrome and the group with meconium aspiration syndrome were better than for HFOV alone or iNO with conventional ventilation (p < 0.05). Marked differences in outcomes were noted among centers (percent death or treatment with extracorporeal membrane oxygenation = 29% to 75%). CONCLUSIONS: We conclude that treatment with HFOV plus iNO is often more successful than treatment with HFOV or iNO alone in severe PPHN. Differences in responses are partly related to the specific disease associated with PPHN.

Thromboembolic risks of left atrial thrombus detected by transesophageal echocardiogram.

Patients with left atrial thrombus are considered at high risk for thromboembolic events. The actual prognosis of these patients and the features most predictive of future events are unclear. We performed transesophageal echocardiograms in 2,894 patients over a 6 1/2-year period; 94 (age 69 +/- 11 years, 59 men, 83 in atrial fibrillation) were found to have left atrial thrombus. The thrombi were considered mobile in 45 patients and 33 patients had thrombus with a maximum dimension > or = 1.5 cm. Seven of the 94 patients with prosthetic valves were excluded from follow-up analysis. Over a follow-up period of 25.3 +/- 19.2 months, 17 patients had suffered a stroke or embolic event (event rate 10.4% per year) and 27 had died (mortality 15.8% per year). Cox proportional hazard regression analysis identified a maximum thrombus dimension > or = 1.5 cm (RR 19, p = 0.002), history of thromboembolism (RR 4.2, p = 0.038), and mobile thrombus (RR 5.3, p = 0.02) as predictors of subsequent thromboembolism. Moderate or severe left ventricular dysfunction was the only significant predictor of death (RR 2.9, p = 0.04). Gender, age, warfarin therapy at follow-up, atrial fibrillation, location (cavity vs appendage) of thrombus, and spontaneous echocardiographic contrast were not significant. Aggressive antithrombotic therapy may be indicated in these high-risk patients.

The natural history of nephrocalcinosis in premature infants treated with loop diuretics.

PURPOSE: We investigated the natural history of nephrocalcinosis in premature infants treated with furosemide and attempted to identify factors to predict infants most at risk. MATERIALS AND METHODS: We evaluated 13 preterm infants in this longitudinal pilot study. During hospitalization and while receiving a loop diuretic nephrocalcinosis developed in each patient. Patients were divided into groups based on resolution (6) and nonresolution (7) according to spontaneous resolution of nephrocalcinosis at any point during followup. The 2 groups were compared to each other and to a control group. RESULTS: Mean followup after discontinuation of furosemide in the resolution versus nonresolution groups was 10.3 and 7.7 months, respectively. Between the 2 groups there was no significant difference in average gestational age, birth weight, number of days hospitalized or on furosemide, or total furosemide dose. Mean calcium-to-creatinine ratio while receiving furosemide at the time nephrocalcinosis developed was 0.38 in the resolution group but 2.23 in the nonresolution group (p < 0.005). Initial calcium-to-creatinine ratio in age matched infants who did not have nephrocalcinosis was 0.4. Frank renal stones developed in 2 of the 7 patients without resolution and 0 of the 6 with resolution. When nephrocalcinosis resolved, it was at a mean of 5.2 months following discontinuation of the diuretic. CONCLUSIONS: Early data indicate that nephrocalcinosis resolves in approximately 50% of premature infants 5 to 6 months after discontinuation of furosemide. The only factor that appears to be predictive of the infants who will have resolution is the calcium-to-creatinine ratio when nephrocalcinosis is diagnosed. In patients without resolution this ratio is much higher than in age adjusted normal controls, while in those with resolution it appears normal for age.

Activated clotting time differential is a superior method of monitoring anticoagulation following coronary angioplasty.

The standard high-range activated clotting time (sHR ACT) is used to monitor anticoagulation postangioplasty (PTCA), but may be unreliable. We assessed the accuracy of a new method we termed the ACT differential (ACT Diff), obtained by measuring the difference between an sHR ACT and a heparinase ACT from the same sample. Heparinase removes heparin from its sample and provides a current heparin-free baseline. For phase 1 of the study, the sHR ACT, ACT Diff, and laboratory APTT were measured in 250 samples from 75 PTCA patients. In 125 samples with an APTT prolonged but within measurement range, linear regression against the APTT was performed. The correlation coefficient was 0.74 for the ACT Diff and 0.24 for the sHR ACT. An ACT Diff of 15-25 sec was found to equal an APTT of 2.5-3.5 x control. In 50 samples with a normal activated partial thromboplastin time (APT), there was good differentiation by the ACT Diff of results from those adequately heparinized, with a value of 0.9 +/- 4.4 sec. The sHR ACT was 114 +/- 15.5 sec, and could not reliably distinguish between anticoagulated and nonanticoagulated samples. In 75 samples obtained with a high APTT (above measurement range), the ACT Diff was > 30 sec in 95% of samples, and again this allowed differentiation from therapeutic samples. The equivalent sHR ACT was 148 sec, and could not reliably distinguish between anticoagulated and overanticoagulated samples as the ACT Diff could. In phase 2, to examine the clinical usefulness of the ACT Diff, 286 patients were managed post-PTCA by starting heparin when ACT Diff fell to < 50 sec, maintaining ACT Diff at 15-25 sec during heparin infusions, and following cessation of heparin, by removing sheaths when the ACT Diff was < 7 sec. These patients were compared to a control group of 250 patients. Major bleeding (5% vs. 0.5%, P < 0.005) and minor bleeding (30% vs. 13%, P < 0.001) were significantly reduced in the group managed using the ACT Diff. The reduction in bleeding was thought to be due to the rapid availability of reliable results. Abrupt closure was low in both groups (0% with ACT Diff vs. 0.8%). No other thrombotic events occurred. Following phases 1 and 2, the ACT Diff replaced the APTT in all PTCA patients at this institution. In the 18 mo from July 1993, 1,104 patients were managed this way. Incidence of major bleeding (0.2%), transfusion requirement (0.1%), false anneurysm (0.6%), and abrupt closure during heparin infusion (0.1%) remained low. In conclusion, the ACT Diff is more accurate than an sHR ACT, and its clinical use in PTCA patients is associated with a very low incidence of complications from anticoagulation. Its routine use should be considered by units unable to obtain rapid APTT results.

Selection of patients for transesophageal echocardiography after stroke and systemic embolic events. Role of transthoracic echocardiography.

BACKGROUND AND PURPOSE: This study examined whether patients suffering from stroke and other systemic embolic events may be selected for transesophageal echocardiography on the basis of clinical and transthoracic echocardiographic findings. METHODS: We performed transthoracic and transesophageal echocardiography on 824 patients after stroke and other suspected embolic events. Patients were classified into group A if they were in sinus rhythm and had a normal transthoracic echocardiogram. Group B consisted of all other patients. Transesophageal echocardiographic findings of left atrial spontaneous contrast, left atrial thrombus, complex aortic atheroma, and interatrial septal anomalies were correlated with clinical and transthoracic echocardiographic results. RESULTS: Transesophageal echocardiography detected at least one potential source of embolism in 399 patients (49%): spontaneous contrast in 214 patients (26%), left atrial thrombus in 54 (7%), complex atheroma in 111 (13%), and interatrial septal anomalies in 126 (15%). In group A (n = 236), only 3 (1%) had spontaneous contrast, 11 (4.6%) had complex atheroma, and none had left atrial thrombus. In group B (n = 588), 211 patients (36%, P < .001) had spontaneous contrast, 54 (9.2%, P < .001) had atrial thrombus, and 100 (17%, P < .001) had complex atheroma. Interatrial septal anomalies were detected in similar proportions of patients (18% in group A versus 14% in group B). Left atrial spontaneous echo contrast, thrombus, and complex atheroma were significantly more prevalent in older patients, but interatrial septal anomalies were more prevalent in younger patients irrespective of transthoracic echocardiographic findings. Multivariate analysis identified both an abnormal transthoracic echocardiogram and patient age to be independent predictors of transesophageal echocardiographic findings of left atrial spontaneous echo contrast, left atrial thrombus, or complex atheroma. CONCLUSIONS: Transesophageal echocardiography has a low yield for left atrial spontaneous contrast, left atrial thrombus, or complex aortic atheroma in patients with normal transthoracic echocardiogram and sinus rhythm and in younger patients. Interatrial septal anomalies are more prevalent in younger patients. Transthoracic echocardiogram should be performed in patients after stroke or systemic embolic events as a noninvasive screening tool. We recommend transesophageal echocardiogram for patients with abnormal transthoracic echocardiogram and in younger patients when the finding of a patent foramen ovale may contribute to patient management.

Commentary on neonatal ECMO: a North American and Scandinavian perspective.

Randomized clinical trials have become the cornerstone of clinical decision making in neonatal medicine. The need to establish the safety and efficacy of different treatment regimens by means of an unbiased approach has led to the formation of state-agency supported and voluntary national and international networks. These neonatal networks have greatly facilitated the organization of randomized multicenter trials. Most studies aimed to evaluate specific treatment alternatives for common disorders (e.g. surfactant therapy for RDS and iv gammaglobulins for prevention of nosocomial infections are particularly well suited for a randomized clinical trial). However, appraisal of alternative therapies for rare conditions with excessive mortality and high risk for later sequelae is limited by a number of practical and ethical considerations. In view of the complexity of the problems involved it is hardly surprising that only one recent head-to-head trial of conventional therapy versus ECMO has to our knowledge been published (39). In this investigation 28 full-term infants fulfilling standard ECMO criteria were randomly assigned to be transported for ECMO or to receive conventional treatment available on-site. Fourteen of the 15 infants (93%) referred for ECMO survived compared with 7 of 13 (53%) treated conventionally. The long-term outcome was comparable in both groups. These data support previous reports of significantly better survival following ECMO treatment. However, the notion of > 80% mortality on continuation of conventional therapy in this critically ill population may need to be reassessed. HFO is today part of "conventional" therapy in many centers, surfactant is used routinely and a combination of NO and HFO is being evaluated in several clinical trials (57).(ABSTRACT TRUNCATED AT 250 WORDS)

Resolution of left atrial spontaneous echocardiographic contrast after percutaneous mitral valvuloplasty: implications for thromboembolic risk.

Left atrial spontaneous echocardiographic contrast (SEC) is an important marker of increased thromboembolic risk in patients with mitral stenosis. To evaluate the effect of percutaneous transseptal mitral valvuloplasty (PTMV) on SEC, we performed transesophageal echocardiography 1 day before and 3 months after PTMV on 88 consecutive patients. SEC was present in 65 (74%) patients before PTMV and was associated with absence of moderate or severe mitral regurgitation (p = 0.01), a smaller valve area (p = 0.02), an older age (p = 0.04), and atrial fibrillation (p = 0.05). At 3 months, PTMV resulted in a mean absolute and relative increase in valve area of 0.54 +/- 0.36 cm2 and 53% +/- 43%, respectively. SEC resolved in 37 patients but persisted in 28 (32%) patients at the 3-month study. The absolute and relative increase of valve area and worsened mitral regurgitation after PTMV were predictors of resolution of SEC, with the relative increase in valve area being the only significant predictor on multivariate analysis. PTMV frequently results in resolution of SEC, which may have important implications in reducing the thromboembolic risk in these patients.