Bacterial endocarditis in children: clinical and laboratory findings, and the role of echocardiography in its diagnosis and management.

We report clinical and laboratory findings of 15 children with bacterial endocarditis, admitted to the Department of Child Health, University of Indonesia/Cipto Mangunkusumo Hospital from February, 1987 to June, 1989. There were 8 boys and 7 girls with bacterial endocarditis, ranging in age from 10 weeks to 16 years. The diagnosis was suspected because of prolonged fever, with or without other manifestations, i.e. congestive heart failure, refractory anemia, or paroxysmal atrial tachycardia. The underlying heart disease was congenital in 12 cases and rheumatic heart disease in 3 cases. The clinical, electrocardiographic, and radiologic manifestations were generally predominated by the pre-existing heart disease. No 'characteristic' findings of bacterial endocarditis, i.e. Osler's nodes, Janeway lesions or splinter haemorrhages were detected. Positive bacterial culture was obtained in 12 cases; the most frequent bacteria isolated was Pseudomonas aeruginosa (4 cases). Streptococcus viridans was isolated in 2 cases only. Vegetation was visualized echocardiographically in 12 cases; 9 with clear cut evidence of large vegetation, and in the other 3 the vegetation was equivocal. On follow-up they disappeared gradually with clinical improvement. Large vegetation might need 2 full months to disappear echocardiographically. It is concluded that bacterial endocarditis is not a rare complication of structural heart disease in our hospital, with a high mortality rate. The availability of good resolution echocardiography has been very helpful in establishing the diagnosis as well as in following-up patients with bacterial endocarditis.

Secundum atrial septal defect before and after surgery.

Twenty patients with secundum atrial septal defect, who had undergone open heart surgery were studied retrospectively. Girls were more affected than boys; the sex ratio was 1.5:1. Associated cardiac defects were diagnosed in two patients, one with moderate valvular pulmonic stenosis and the other one with small ventricular septal defect. Typical clinical findings consisted of loud first heart sound, widely fixed split second heart sound and soft ejection systolic murmur at the upper left sternal border were heard in all cases. Mid diastolic murmur due to relative tricuspid stenosis was detected in most cases (75%). Electrocardiographic findings included right axis deviation, prolonged PR-interval and right atrial enlargement were found in 50%, 15% and 60% of cases, respectively. Incomplete right bundle branch block and right ventricular enlargement were found in all cases, as was cardiomegaly with increased vascular markings were found in all cases. Paradoxical ventricular septal motion and visualization of the atrial septal defect were seen in 95% and 75% of cases, respectively. Cardiac catheterization was performed in 19 patients (95%). The pulmonary-systemic flow ratio (Qp/Qs) ranged from 1.7 to 6.3 (mean 2.9 +/- 0.67), and was correlated to the presence of mid diastolic tricuspid flow murmur and paradoxical ventricular septal motion. Simple closure of the defect was the procedure of choice, but in one patient (5%) pericardial patch was used to close the very large defect. The mortality rate was 10 per cent. Physical retardation was found in all boys and 50% of girls, before surgery. Body weight percentile increased in most cases (61.1%), while body height percentile increased in only 5.6% of cases, postoperatively. Ejection systolic murmur at the upper left sternal border was still detected in one patient (5.6%). Incomplete right bundle branch block persisted in all cases, while cardiomegaly was still found in 5.6% of cases followed-up six months to five years after surgery. There was no residual left ventricular dysfunction in all cases.

Patent ductus arteriosus before and after surgery.

Twenty five patients with patent ductus arteriosus, who had undergone surgical closure were studied retrospectively. Girls were more affected than boys; the sex ratio was 4:1. Associated cardiac lesions were diagnosed in 3 patients, two with ventricular septal defect and one with congenital mitral stenosis. Congestive heart failure was diagnosed in 5 patients before surgery. Typical continuous murmur was heard in most cases (76%), while in the rest only systolic murmur was detected. Electrocardiographic left atrial enlargement, left ventricular hypertrophy and right ventricular hypertrophy were found in 8%, 48% and 40%, respectively. Cardiomegaly with increased pulmonary vascular markings was found in 60% of cases, while ratio of left atrial to aortic root diameter greater than 1.2 was detected in 60% of patients. The PDA could be directly visualized by echocardiography in 15 cases. Cardiac catheterization was performed in 17 cases, 47% with hyperkinetic pulmonary hypertension, 41% with high pulmonary flow without pulmonary hypertension and 12% with mild increased pulmonary flow. The pulmonary-systemic flow ratio (Qp/Qs) was more correlated to pulmonary vascular markings rather than to cardio-thoracic ratio. Division of the ductus was the procedure of choice, but in 16% of cases ductal ligation was performed because of technical reasons. Postoperative catch-up in both weight and height was observed more clearly in children operated at earlier age. Ejection systolic murmur was still detected in 2 patients, in whom hyperkinetic pulmonary hypertension existed prior to surgery. No cardiomegaly was found in patients followed-up 1 year or more after surgery. The mortality was nil.