Taquicardia fetal: estudio multicéntrico retrospectivo en 9 hospitales españoles / Fetal tachycardia: a retrospective study in 9 Spanish centers

Introducción y objetivo: El tratamiento óptimo de la taquicardia fetal es todavía objeto de controversia. El objetivo de este estudio es revisar el manejo y la evolución de los fetos diagnosticados de taquicardia en 9 centros españoles. Método: Se llevó a cabo un estudio multicéntrico retrospectivo, con análisis de todos los fetos con taquicardia diagnosticados en 9 centros españoles entre enero de 2008 y septiembre de 2010. Resultados: Se registraron 37 casos, un 30% hidrópicos. Un total de 26 casos no presentaba hidropesía; 4 de ellos se diagnosticaron de flutter auricular –cardioversión con éxito en todos, intraútero o posnatalmente– y 22 de taquicardia supraventricular (TSV), 17 con intervalo ventriculoauricular (VA) corto y 5 con intervalo VA largo. El fármaco inicial en la mayoría de los casos fue la digoxina. La taquicardia se controló prenatalmente en el 93% de las TSV con VA corto y en el 50% con VA largo. La digoxina resultó eficaz en los fetos con VA corto, pero ineficaz en los casos con VA largo (p= 0,019). Un feto con TSV con disfunción ventricular falleció. Asociaron hidropesía 11 casos, todos ellos diagnosticados de TSV. La estrategia terapéutica fue muy variable en este grupo. Fallecieron 5 de los fetos hidrópicos: 1 posnatalmente, 2 intraútero muy precozmente tras empezar el tratamiento, y 2 intraútero a pesar de haber convertido a ritmo sinusal con éxito (1 estando en tratamiento con flecainida y 1 con sotalol) . Conclusiones: En nuestra serie se ha registrado una mortalidad muy alta de los fetos hidrópicos. Proponemos un nuevo protocolo de tratamiento concordado para mejorar la evolución de la taquicardia fetal (AU)

Introduction and objective: Optimal treatment for fetal tachycardia is still controversial. The aim of this study is to review the actual management and outcome of fetal tachycardia in 9 Spanish centers. Method: Retrospective multicentric study: analysis of all fetuses with tachycardia diagnosed at 9 Spanish centers between January 2008 and September 2010. Results: 37 cases were registered, 30% of which were hydropic. We had 26 no hydropic cases, of which 4 atrial flutter –all of them successfully cardioverted intrautero or after delivery– and 22 with supraventricular tachycardia (SVT), of which 17 short ventriculo-auricular (VA) interval and 5 long VA interval. Digoxin was the drug of choice in most cases. Prenatal control of the tachycardia was achieved in 93% of treated SVT with short VA interval and 50% of long VA, being digoxine effective in short VA but not long VA interval (p= 0.019). 1 fetus with supraventricular tachycardia with ventricular dysfunction died. 11 cases were hydropic, all of them diagnosed as SVT. Management strategies were highly diverse in this group. 5 patients died: 1 after delivery, 2 intrautero very shortly after starting treatment, and 2 intrautero in spite of being successfully cardioverted to sinus rhythm (1 with sotalol, 1 with flecainide). Conclusions: Hydropic fetuses have shown a high mortality rate in our population, which calls for further studies and unification of criteria. Here we propose a common protocol aimed at improving the outcome of fetal tachycardia (AU)

Bradicardia fetal: estudio multicéntrico retrospectivo en 9 hospitales españoles / Fetal bradycardia: A retrospective study in 9 Spanish centers

OBJETIVO: Revisar el manejo actual y la evolución de la bradicardia fetal en 9 centros españoles. MÉTODO: Estudio multicéntrico retrospectivo: análisis de todos los fetos con bradicardia diagnosticados en 9 centros españoles entre enero de 2008 y septiembre de 2010. Los mecanismos electrofisiológicos responsables de la bradicardia fetal se estudiaron mediante ecocardiografía. RESULTADOS: Se registraron 37 casos: 3 fetos con bradicardia sinusal, 15 con extrasistolia auricular no conducida y 19 con bloqueo auriculoventricular (AV) de alto grado. Bradicardia sinusal: el 100% asoció patologías severas. Extrasistolia auricular no conducida: excelente pronóstico, pero un caso desarrolló posnatalmente taquicardia supraventricular. Entre los bloqueos AV de alto grado, el 16% asociaban cardiopatía congénita con isomerismo, el 63% anticuerpos antiRo/SSA maternos y el 21% fueron de etiología desconocida. La mortalidad global de los bloqueos AV fue del 20% (37% si consideramos la interrupción voluntaria del embarazo). Factores de riesgo fueron: asociar una cardiopatía congénita, hídrops y/o disfunción ventricular. El tratamiento fue variable según el centro, se administraron corticoides en el 73% de los bloqueos de grado III inmunomediados y en el único caso de bloqueo de grado II inmunomediado. En un seguimiento medio de 18 meses, se implantaron marcapasos en el 58% de los bloqueo AV de alto grado. CONCLUSIONES: La bradicardia fetal sostenida precisa siempre de un estudio exhaustivo, incluso en el caso de la bradicardia sinusal. La extrasistolia auricular no conducida tiene buen pronóstico pero puede asociar taquicardia. El bloqueo AV de alto grado fetal tiene todavía una morbimortalidad significativa y su tratamiento es controvertido

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

[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.

Defecto congénito de pericardio: a propósito de tres casos / Congenital pericardial defects: a report of three cases

Introducción: La atrofia prematura de la vena cardinal común producirá defectos en el pericardio y, a veces, también pleurales. Esos defectos pericárdicos pueden ser asintomáticos o, por el contrario, producir dolor inespecífico, dolor anginoso, isquemia miocárdica, embolias, arritmias y muerte súbita. Las pautas de actuación varían, desde la corrección quirúrgica de todo defecto a una actitud expectante.Casos clínicos: Presentamos tres casos de defecto congénito de pericardio, dos de ellos correspondientes a dos niñas lactantes de 3 y 11 meses respectivamente, en cuya radiografía de tórax se observó una alteración compatible con un defecto parcial de pericardio, confirmado con posteriores exámenes (ecocardiograma, angiocardiografía, resonancia magnética nuclear). El tercer caso se diagnosticó durante el transcurso de una intervención quirúrgica de ductus permeable, en la que pudo visualizarse directamente la ausencia de pericardio.Discusión: El interés de nuestros casos radica en la posibilidad de establecer un diagnóstico de presunción mediante la radiografía simple (en dos de ellos). Se concluye destacando la importancia de tener un alto índice de sospecha de anomalía congénita por el riesgo vital que comportan ciertos defectos parciales de pericardio ante la posibilidad de herniación ventricular

Introduction: Premature atrophy of the left common cardinal vein results in pericardial and pleuropericardial defects. Patients with these congenital defects can be entirely asymptomatic, but they may experience vague chest pain, angina, myocardial ischemia, emboli, dysrhythmia and sudden death. Practical guidelines suggest different approaches, from expectant management to surgical correction of the defects.Patients and method: We report three cases of this congenital entity. Two involved three-month-old and eleven-month-old girls with asymptomatic pericardial defects, discovered incidentally on chest X-ray and later confirmed by other techniques (echocardiography, angiocardiography, magnetic resonance imaging). The third case was diagnosed during surgical repair of a patent ductus in which the absence of pericardium was observed.Discussion: We highlight the fact that, in two of our cases, it was possible to establish a presumptive diagnosis on the basis of plain chest radiography. We conclude by stressing the importance of maintaining a high degree of suspicion for this congenital anomaly because of the life-threatening risk associated with certain partial pericardial defects should they result in ventricular herniation

[Pericardial defect with atrial herniation]. / Defecto pericárdico con herniación auricular.

Pericardial defects are rare in childhood and outcome is usually benign. Patients can be asymptomatic, but they may experience vague chest pain, angina, myocardial ischemia, emboli, and arrhythmia and some cases of sudden death have even been described in the literature. We report the case of a 3-month-old girl who, in the context of an episode of fever, underwent chest X-ray examination, which showed a left heart border anomaly. This finding strongly suggested a congenital partial pericardial defect, which was subsequently confirmed by other techniques. The interest of this case lies in the ability of the pediatrician to establish a presumptive diagnosis by examining the chest X-ray. We conclude by stressing the need for a high degree suspicion for congenital heart anomalies because of the life-threatening nature of some partial pericardial defects, which can lead to left-ventricular herniation.

Defecto pericárdico con herniación auricular / Pericardial defect with atrial herniation

Los defectos del pericardio constituyen una entidad poco común en pediatría con curso generalmente benigno. Los pacientes pueden estar asintomáticos, o presentar dolor inespecífico, dolor anginoso, isquemia miocárdica, embolias, arritmias e incluso se han descrito en la literatura médica casos de muerte súbita. Se presenta el caso de una niña lactante de 3 meses de edad, a quien, en el curso de un síndrome febril, se le realizó una radiografía de tórax, en la que se observó una alteración en el borde izquierdo de la silueta cardíaca. Dicho hallazgo era muy indicativo de un defecto parcial congénito de pericardio que fue confirmado con posteriores exámenes. El interés de nuestro caso radica en la posibilidad de establecer un diagnóstico de presunción por parte del pediatra al visualizar la radiografía de tórax. Se concluye destacando la importancia de tener un alto índice de sospecha de anomalía congénita por el riesgo vital que comportan ciertos defectos parciales de pericardio ante la posibilidad de herniación ventricular (AU)

The effect of chronic phenytoin treatment on serum lipid profile in adult epileptic patients.

Total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and very-low-density lipoprotein cholesterol, apolipoproteins A, A1, and B and gamma-glutamyltransferase (ggt) serum concentrations were measured in 100 adult epileptic patients receiving chronic phenytoin (PHT) treatment and in 100 control subjects. In relation to controls, patients showed higher HDL cholesterol, apolipoproteins A and A1, and ggt levels and lower LDL cholesterol and apolipoprotein B values; the significance of the results was greater in women than in men. Among patients, ggt levels were positively correlated with PHT plasma concentrations; likewise, a negative correlation was found between the apolipoprotein A/A1 ratio and the PHT and ggt plasma levels, and a positive correlation between the apolipoprotein A/A1 ratio and the LDL/HDL cholesterol ratio. These data indicate that PHT exerts a beneficial effect on the serum lipids profile.