Two-dimensional echocardiographic predictors of coarctation of the aorta.

BACKGROUND: Coarctation of the aorta is a very common congenital heart malformation. It is frequently associated with other abnormalities. Echocardiography is the diagnostic modality for congenital heart disease. The carotid-subclavian artery index and the isthmus/descending aorta index were proposed for establishing the diagnosis of coarctation of the aorta. OBJECTIVES: The objectives were to evaluate such indexes and to look for other echocardiographic predictors of coarctation of the aorta. METHOD: Echocardiography was reviewed for infants with coarctation of the aorta, as well as a control group, using the Echo PAC Dimension. Standard measurements were obtained from different sites of the aortic arch. RESULTS: A total of 31 infants 3 months or less with coarctation of the aorta and 50 infants with no coarctation of the aorta were reviewed. Abnormal aortic valve was present in 65% of those with coarctation of the aorta. The diameters of the proximal and the distal transverse aortic arch were smaller in the coarctation of the aorta group. The distance between the aortic arch branches was longer in the coarctation of the aorta group. Apart from the ratio between distance 2 and the ascending aorta, other ratios/indexes were smaller in the coarctation of the aorta group than in the control group. CONCLUSION: The presence of abnormal aortic valve, a carotid subclavian index <1.1, I/AAo ratio <0.53, and DTA/AAo ratio <0.6 suggest the presence of coarctation of the aorta. Neonates with large patent ductus arteriosus and any of these findings need close observation until the patent ductus arteriosus closes. If the arch is difficult to assess by two-dimensional echocardiography, the patient may need further imaging to rule out coarctation of the aorta.

Efficacy of implementation of a 5 scale pediatric triage and acuity scale in pediatric emergency, Saudi Arabia.

OBJECTIVES: To evaluate the effectiveness of implementation of the pediatric Canadian Triage and Acuity Scale (Ped-CTAS) for children visiting the pediatric emergency department (ED). METHODS: This cross-sectional study evaluated all children presented to the ED during a 9-day period in March 2010. The Ped-CTAS triage system was used. Triage performance was analyzed on the basis of quality indicators, rate of admissions, rate of referral, observation duration, and relationship between investigations requested and CTAS level. RESULTS: During the study period, 3,337 patients were triaged. Overall, 4 patients (0.1%) were in triage level 1, 356 (12%) were level 2, 655 (22%) were level 3, 1810 (60%) were level 4, and 189 (6%) were level 5. The left without being seen rate was 6.25%. A triage duration of 5 minutes or less was carried out for 97% of cases. Within the CTAS time objectives, the waiting time to nurse and physician was 100% for cases triaged to level 1. The proportion of cases who needed observation was 100% for level 1, 85% for level 2, 53% for level 3, 33% for level 4, and 26% for level 5. The proportion of patients admitted to the hospital was 100% for level 1. The lower the level (more acute and emergent the condition) the more use of the laboratory and radiological investigations. CONCLUSION: The pediatric CTAS triage system is a good tool for categorizing pediatric patients attending the ED. Stratified by triage level, triage indicators can be used as indicators of ED performance.

Amplatzer septal occluder and atrioventricular block: A case report and literature review.

Transcatheter closure of secondum atrial septal defect (ASD) is an alternative option to open heart surgery with good short and long-term outcomes. For this purpose, the Amplatzer septal occluder (ASO) device is widely used. Arrhythmias are known complications of ASD device closure including atrial ectopy and heart block. We report a seven-year-old female patient who developed second degree atrioventricular block (AVB) within few hours after ASD device closure using ASO device. At the seventh post-procedure day; while under close observation; patient regained sinus rhythm which was maintained thereafter. A 3-day course of prednisolone was given.

Maternal knowledge and use of folic acid among Saudi females.

OBJECTIVE: To explore and find out the level of awareness regarding folic acid's (FAs) importance, current use, and timing of administration among pregnant Saudi females. METHODS: This is a cross-sectional study conducted randomly among women aged 18-45 years old, attending the Antenatal and Gynecology Clinics at the Maternity and Children's Hospital, Al-Qassim, Kingdom of Saudi Arabia from January to November 2012. A total of 1250 subjects were approached, and 1000 women expressed their verbal consent to participate. The questionnaire consisted of 17 items, and results were analyzed using univariate and multivariate analysis. RESULTS: A total of 88.4% of women were aware of FA. However, only 4.4% of them took FA before pregnancy. Compared to highly educated women (20.4%), only 5% of illiterate women use FA during the first trimester of their pregnancy. Univariate and multivariate analysis showed that educational level had a significant association with FA awareness and use (p=0.001; odds ratio: 0.000; 95% confidence interval: 1.001 to 1.080). Most women recall hearing of FA from their doctors. Only 48 women reported a history of a previous child with congenital anomalies, and 4 of them (8.3%) of them used FA before pregnancy. CONCLUSION: We found that only 4.4% of the studied women use FA in their preconceptional period. The higher the educational level, the more the knowledge, and frequent use of FA. Poor level of awareness among lower educated woman requires medical authorities to broadcast the importance of FA, and there may be a need to fortify food with FA.

Safety and usefulness of outreach clinic conducted by pediatric echosonographers.

BACKGROUND: Outreach echocardiographic services led by cardiac sonographers may help district level hospitals in the management of patients suspected to have cardiac anomalies. However, the safety and utility of such an approach is not tested. METHODS: We retrospectively reviewed our experience of patients seen in the outreach visits by the echocardiographers alone and subsequently reviewed in the pediatric cardiology clinic. Comparison between the diagnosis made by the echocardiographer and the consultant pediatric cardiologist were done. We defined safety as no change in patient management plan between the outreach evaluation and the pediatric cardiology clinic evaluation, and we defined usefulness as being beneficial, serviceable and of practical use. RESULTS: Two senior echocardiographic technicians did 41 clinic visits and over a period of 17 months, 623 patients were seen. Patients less than 3 months of age constitute 63% of the total patients seen. Normal echocardiographic examinations were found in 342 (55%) of patients. These patients were not seen in our cardiology clinic. Abnormal echocardiographic examinations were found in 281 (45%) of patients. Among the 281 patients with abnormal echos in the outreach visits, 251 patients (89.3%) were seen in the pediatric cardiology clinic. Comparing the results of the outreach clinic evaluation to that of the pediatric cardiology clinic, 73 patients (29%) diagnosed to have a minor CHD turned to have normal echocardiographic examinations. In all patients seen in both the outreach clinics and the pediatric tertiary cardiac clinics there was no change in patient's management plan. CONCLUSIONS: Outreach clinic conducted by pediatric echo sonographers could be useful and safe. It may help in reducing unnecessary visits to pediatric cardiology clinics, provide parental reassurance, and help in narrowing the differential diagnosis in critically ill patient unable to be transferred to tertiary cardiac centers provided it is done by experienced echosonographers.

Incidence of severe congenital heart disease at the province of Al-Qassim, Saudi Arabia.

UNLABELLED: Worldwide, congenital heart defects (CHD) are the leading cause of infant deaths owing to congenital anomalies. Knowing the actual incidence of severe CHD is important for defining the requirement for resources and the burden of disease within the total population. OBJECTIVES: The aim of the study is to estimate the incidence of severe CHD at the province of Al-Qassim as a reflection of that in the Kingdom of Saudi Arabia. STUDY DESIGN: A retrospective database review of all cases diagnosed to have severe CHD at Prince Sultan Cardiac Center-Qassim during a 3-year period from January 2008 to December 2010. RESULTS: During the study period, 316 patients were diagnosed to have severe CHD. During the 3-year study period, the total live birth at the province of Al-Qassim was 58,908. The incidence of severe CHD is 5.4/1000 live birth/year. Sixty-five percent of cases were diagnosed at less than 2 months of age, with a median age at diagnosis of 45 days (range of 1 day to 1 year). Ventricular septal defect was the most common lesion diagnosed (22.5%). Collectively, prostaglandin-dependent lesions constitute 38% of cases. Fifteen percent of patients were proved to have a syndrome. The most common syndrome was Down syndrome. CONCLUSION: . Severe CHD is a major health problem at the Kingdom of Saudi Arabia and worldwide. The incidence of severe CHD likely to require intervention in infancy, in the province of Al-Qassim, Saudi Arabia, is 5.4 per 1000 live births.

Waiting time for transfer of patients with prostaglandin dependant congenital heart defects to tertiary cardiac centers.

UNLABELLED: Worldwide congenital heart defects (CHD) are the leading cause of infant deaths owing to congenital anomalies. Delay in diagnosing and operating in neonates with prostaglandin dependant CHD may lead to significant morbidity and mortality. OBJECTIVES: To assess the time interval needed for acceptance and transfer of patients with critical CHD to a tertiary cardiac center and the impact on the patient's survival. STUDY DESIGN: Retrospective database reviews of all cases diagnosed to have prostaglandin dependant (PG) CHD at Prince Sultan Cardiac Center-Qassim during a 43 months period (from May 2007 to December 2010). RESULTS: During the study period 104 patients were diagnosed to have PG dependant CHD. Patients with PG dependant systemic circulation constitute 60% of patients. Patients with ventricular septal defect (VSD) associated with coarctation of the aorta constituted 16% of patients. The mean waiting time for transfer to a tertiary cardiac center was 10 ± 10 days. Twenty-two (21%) patients died while waiting for acceptance and transfer. Eleven patients were diagnosed with hypoplastic left heart syndrome (HLHS). There was no significant difference in the waiting time for those with or without HLHS, with a mean of 9 days for both. Six of our patients had infections with positive blood cultures. The mean waiting period for those with proved infection was 25 days compared with 8 days for those with no proved infection (p value < 0.005). CONCLUSION: There are a significant number of patients with severe CHD who die while waiting for acceptance and transfer to a tertiary cardiac center. The causes for delay could be the presence of infection, prematurity and low birth weight. The limited numbers of tertiary cardiac centers in Saudi Arabia as well as cardiac ICU beds are among the factors delaying the acceptance of patients requiring cardiac surgery.

Transcatheter closure of patent ductus arteriosus in infantile form of Scimitar syndrome with a type II Amplatzer Ductal Occluder.

We report a unique case of infantile form of Scimitar syndrome with a patent ductus arteriosus and pulmonary hypertension. The PDA was closed percutaneously using the new Amplatzer Ductal Occluder device type II.

Outcome of Norwood and Damus-Kaye-Stansel procedures for univentricular congenital heart anomalies.

OBJECTIVES: To review the experience with Norwood and Damus-Kaye-Stansel (DKS) staged repair in the management of hypoplastic left heart syndrome (HLHS), or functional single ventricle (FSV) with systemic outflow tract obstruction (SOTO). METHODS: A retrospective study was conducted from a single center from January 2001 to September 2007 at the Cardiac Sciences Department, King Abdulaziz Cardiac Center, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia. The cardiac departmental database was reviewed, together with the echocardiographic findings. Demographic data representing age and weight at operation, gender, cardiac anatomy, non-cardiac abnormalities, and operative details were collected. RESULTS: Twenty-eight patients with a diagnosis of HLHS were included in the study. The mean +/- SD for weight was 3.4 +/- 0.85kg and 32 +/- 37 days for age. All infants at our institution who underwent a Norwood or DKS surgery for HLHS, or other forms of FSV with SOTO were included. All included patients underwent first stage palliation consisting of either a classical Norwood procedure in 6/23 (21%) patients, or a modified Norwood with right ventricle to pulmonary artery (RV-PA) conduit in 22/28 (79%) patients. After first stage palliation, 23 patients (82%) survived, and all but one underwent second stage palliation with bidirectional cavopulmonary anastomosis (BCPA). The survival rate after second stage repair was 91%. Subsequently, 4 patients completed a third stage Fontan with 100% survival. All deceased patients had HLHS. CONCLUSION: The Norwood procedure is applied to a heterogeneous group of patients with variable outcomes in certain subgroups. Patients with HLHS palliated with the Norwood procedure are at a greater risk for morbidity and mortality compared to those with other forms of FSV with SOTO.

Persistent fifth aortic arch diagnosed by echocardiography and confirmed by angiography: Case report and literature review.

Persistent fifth aortic arch is a rare congenital anomaly that can be discovered incidentally or at postmortem exam. It can be associated with major congenital heart malformations involving the systemic or the pulmonary circuits. It usually has no clinical significance but can be either, beneficial as in systemic outflow tract obstructions or cause hemodynamic compromise when associated with a significant left to right shunt. We report an infant with persistent fifth aortic arch associated with Shone's complex diagnosed accurately by transthoracic echocardiography and confirmed by cardiac catheterization and computed tomography.