[Fetal bradycardia: a retrospective study in 9 Spanish centers]. / Bradicardia fetal: estudio multicéntrico retrospectivo en 9 hospitales españoles.

OBJECTIVE: The aim of this study is to review the current management and outcomes of fetal bradycardia in 9 Spanish centers. METHODS: Retrospective multicenter study: analysis of all fetuses with bradycardia diagnosed between January 2008 and September 2010. Underlying mechanisms of fetal bradyarrhythmias were studied with echocardiography. RESULTS: A total of 37 cases were registered: 3 sinus bradycardia, 15 blocked atrial bigeminy, and 19 high grade atrioventricular blocks. Sinus bradycardia: 3 cases (100%) were associated with serious diseases. Blocked atrial bigeminy had an excellent outcome, except for one case with post-natal tachyarrhythmia. Of the atrioventricular blocks, 16% were related to congenital heart defects with isomerism, 63% related to the presence of maternal SSA/Ro antibodies, and 21% had unclear etiology. Overall mortality was 20% (37%, if terminations of pregnancy are taken into account). Risk factors for mortality were congenital heart disease, hydrops and/or ventricular dysfunction. Management strategies differed among centers. Steroids were administrated in 73% of immune-mediated atrioventricular blocks, including the only immune-mediated IInd grade block. More than half (58%) of atrioventricular blocks had a pacemaker implanted in a follow-up of 18 months. CONCLUSIONS: Sustained fetal bradycardia requires a comprehensive study in all cases, including those with sinus bradycardia. Blocked atrial bigeminy has a good prognosis, but tachyarrhythmias may develop. Heart block has significant mortality and morbidity rates, and its management is still highly controversial.

[Mid-term results of percutaneous closure of atrial septal defect in children]. / Resultados a medio plazo del cierre percutáneo de la comunicación interauricular en niños.

OBJECTIVE: To evaluate the medium-term results of percutaneous closure of atrial septal defect. METHODS: Twenty-two children (mean weight, 23 11kg; mean age, 5.7 2.4 years) underwent percutaneous atrial septal defect closure under general anesthesia. The procedure was monitored by transesophageal echocardiography. DAS-Angel Wings (n4) and the Amplatzer device (n18) were used. RESULTS: Mean pulmonary artery pressure was 13 2.8mmHg, mean pulmonary vascular resistance was 1.50.5U/m2 and mean Qp/Qs flow ratio was 2.2 0.6. The mean diameter of the defects was 14.5 6.3mm by transesophageal echocardiography OmniPlane measurement and 15.95.3mm using balloon occlusion reference. A total of 31 devices were used: 4 Angel Wings and 27Amplatzer devices. Twelve Amplatzer devices were withdrawn through the introducer without complications, 5 due to a discrepancy in the size of the left auricle, 4 because they were too small to stabilize in the septum and 3 due to defective opening in the left auricle. In 19 patients implantation was successful. In 17 patients transthoracic color Doppler echocardiography carried out 24 hours after the procedure showed a minimal shunt which was no longer present 1 month later. The mean time of discharge was 38 12 hours after the procedure. After a mean follow up 15 6 months the patients remain asymptomatic with no clinical or technical problems. CONCLUSION: The success rate of percutaneous closure of atrial septal defects in well-selected patients was high and presented no complications.

[Percutaneous closure of atrial septal defects: midterm results of a new therapeutic strategy]. / Cierre percutáneo de la comunicación interauricular: resultados a medio plazo de esta nueva opción terapéutica.

OBJECTIVE: To evaluate the midterm results of percutaneous closure of the atrial septal defect using two new devices. PATIENTS AND METHODS: Nine children (weight 19.7 +/- 7 kg, age 5.1 +/- 1.9 years) underwent percutaneous type II atrial septal defect closure through the antegrade pathway under general anaesthesia, and monitored by transesophageal echocardiography. The closing devices used were DAS-Angel Wings and Ampaltzer. RESULTS: The hemodynamic results were: mean diameter of the defects was 11.4 +/- 2 mm by TEE measurement and 12.3 +/- 2.6 mm using balloon occlusion reference. Mean pulmonary artery pressure was 12.7 +/- 2 mmHg and mean pulmonary vascular resistance 1.5 +/- 0.5 U/m2. A total of 13 devices were used: 9 Amplatzer and 4 DAS-Angel Wings. Four Amplatzer through the introducer were retrieved without complications. Two of which because of lack of sufficient stability in the atrial septum because they were too small inappropriate and the other two because of inappropriate expansion of distal disk of the device. Finally in all patients the device was a successfully deployed. The angiographic evaluation immediate post-procedure showed a minimal shunt in five patients that was no longer present by color Doppler echocardiography 24 hours later. The children were discharged 38 +/- 12 hours after the procedure and at a mean follow up of 9.6 +/- 2.2 months they remain asymptomatic without any clinical or technical problems. CONCLUSION: With the right selection of patients percutaneous closure of atrial septal defects can obtain a very high success rate without complications.

[The midterm evolution in the percutaneous closure of ductus arteriosus with the Rashkind prosthesis]. / Evolución a medio plazo del cierre percutáneo del ductus arterioso mediante la prótesis de Rashkind.

Background percutaneous PDA occlusion has been proposed as a valid therapeutic alternative to surgical closure. Between April 1990 and July 1994, 44 patients underwent percutaneous PDA occlusion. Thirteen patients were less than 18 months old and weighed 8.7 +/- 3.2 Kg (Group I). Thirty-one patients, older than 18 months of age, had a mean weight of 36.8 +/- 20.6 Kg (Group II). Four patients in group I and two in group II had associated cardiac anomalies Residual shunt after percutaneous occlusion was studied by color Doppler. Fifty-one occluding devices were used. Forty-nine were implanted and there were two device embolizations. Twelve devices were implanted in group I. One device needed surgical removal from the right ventricle where it had embolized. In group II, 31 devices were implanted and one embolized to the descending aorta and was percutaneously removed through the femoral artery sheath. In two patients of group I and four of group II, a second device was implanted. The total occlusion rate immediately after implantation at 24 hours and at 6 months was 75%, 83% and 83% in group I and 64.5%, 77% and 84% in group II. After implantation of a second device the total occlusion rate without residual shunt reached 100% in group I (after 16 +/- 12 months follow-up) and 97% in group II (after 23 +/- 16 months of follow-up). We conclude that percutaneous ductal occlusion with a Rashkind device is a valid therapeutic alternative to surgical closure in all age groups.

[Outcome of anatomical correction of transposition of the great vessels in the neonatal period]. / Resultados de la corrección anatómica en la transposición de las grandes arterias en el periodo neonatal.

Between february 1992 to January 1994, anatomic correction was performed on 15 patients with transposition of the great arteries and intact ventricular septum. The mean age was 8.3 +/- 2.9 days and the mean weight 3.39 +/- 0.39 Kg. Before the operation, 13 patients (86.6%) received prostaglandin El infusion and 13 patients (86.6%) underwent Rashkind septostomy. Mean aortic cross-clamps was 56 +/- 11 minutes and mean cardiopulmonary bypass was 108 +/- 91 minutes. Hospital mortality rate was 13%. Mean extubation period was mean discharge from ICU was 13.1 +/- 12.3 days and discharge of hospital was 17.8 +/- 7.5 days. The mean followup period was 11.4 months. All the patients remained asymptomatic with adequate psychomotor and ponderal development. All patients remained in sinus rhythm. Pulmonary suture gradient was over 60 mm Hg in five patients (33%). One patient needed reintervention and four pulmonary artery angioplasty (PAA) that was successful. In the midterm follow-up pulmonary stenosis suture was the most common complication. If the stenosis is severe and PAA should be the initial approach.

[The myxoma syndrome: "cardiac myxoma, cutaneous pigmented lesions and peripheral and endocrine neoplasms". Apropos 2 cases]. / Síndrome mixoma: "Mixoma cardíaco, lesiones pigmentadas cutáneas y tumores periféricos y endocrinos". A propósito de dos casos.

We present two cases, mother and son, with "syndrome myxoma". Both had cardiac myxoma and cutaneous pigmented lesions. The son had a cutaneous myxoma and the mother had been diagnosed as having Cushing's syndrome caused by adrenal adenoma. The "syndrome myxoma" is a systemic disease which causes cardiac, cutaneous, and breast myxomas, adrenal disease, testicle and pituitary tumours. Whenever it is diagnosed all first relatives should be tested for the syndrome. The patient should be re-examined every six-twelve months, due to frequent recurrence of cardiac myxoma.

[Main vascular access in situations of extreme urgency: intra-osseous infusion]. / Acceso vascular prioritario en situaciones de extrema urgencia: la infusión intraósea.

The intraosseous infusion is an easy technique to learn. The chosen places for infusion are: proximal tibia, distal tibia and distal femur. We have used this technique on thirteen occasions in emergency situations. In all cases, access was achieved in less than one minute. Saline, glucose and Ringer's solutions, sodium bicarbonate, blood, calcium chloride, epinephrine, atropine, succinylcholine, dopamine, dobutamine, isoproterenol, lidocaine and anticonvulsants may be infused. The doses are the same as those used in parenteral access and its efficacy is similar to that of a central venous line. Complications are rare. The most frequent is subcutaneous, and occasionally subperiosteal infiltration. Osteomyelitis appeared in 0.6% of the cases. The intraosseous infusion provides rapid, easy and safe vascular access in emergency situations. Therefore, we believe that this technique should be chosen in pediatric patients.