Maternal self-administered fetal heart rate monitoring and transmission from home in high-risk pregnancies.

OBJECTIVES: To evaluate the feasibility of high-risk pregnancy surveillance by patient-directed fetal heart rate monitoring and transmission, and to assess patient satisfaction with this technology. METHODS: Thirty-six women with high-risk pregnancies performed daily non-stress tests at home and transmitted the data to our perinatal care center by telephone. At each transmission, patients were asked by a physician about perceived fetal movements and uterine contractions and given the results. If the tracing was unsatisfactory, further evaluation was performed. In addition, patients completed a questionnaire on quality of life and anxiety state before and after the study. RESULTS: All patients were able to perform the tests and transmissions. The quality of recorded data was significantly correlated with maternal body mass index, but not with gestational age at the time of monitoring or birth weight. Thirty-nine of the total 562 tracings (6.9%) were inconclusive or non-reassuring. After repeated testing, 32 of them (82%) were considered normal, and seven patients (18%) were referred for additional in-hospital evaluation. Of this group, four were discharged for further surveillance with routine home monitoring and the remaining three were hospitalized for continued evaluation. There were no significant immediate adverse maternal or neonatal outcomes as a result of the monitoring. Patient satisfaction was high. CONCLUSIONS: Daily home FHR monitoring in high-risk patients is safe and feasible at all gestational ages, based on this initial pilot evaluation. It is easily and reliably performed and accepted by patients with a high level of satisfaction.

Citizen centered health and lifestyle management via interactive TV: The PANACEIA-ITV health system.

In the context of an IST European project with acronym PANACEIA-ITV, a home care service provisioning system is described, based on interactive TV technology. The purpose of PANACEIA-ITV is to facilitate essential lifestyle changes and to promote compliance with scientifically sound self-care recommendations, through the application of interactive digital television for family health maintenance. The means to achieve these goals are based on technological, health services and business models. PANACEIA-ITV is looking for communication of monitoring micro-devices with I-TV set-top-boxes using infrared technology, and embodiment of analogous H/W and S/W in the I-TV set-top-boxes. Intelligent agents are used to regulate data flow, user queries as well as service provisions from and to the household through the satellite digital platform, the portal and the back-end decision support mechanisms, using predominantly the Active Service Provision (ASP) model. Moreover, interactive digital TV services are developed for the delivery of health care in the home care environment.

Self-efficacy and physical activity in adolescents with trivial, mild, or moderate congenital cardiac malformations.

Our purpose was to examine the cognitive processes that influence involvement in physical activity among 100 adolescents, 55 boys and 45 girls, ranging in age from 12 to 18 years, with trivial, mild, or moderate forms of congenital cardiac disease. We hypothesized, first, that the severity of the congenital cardiac malformation itself has an indirect effect on self-efficacy regarding physical activity, and that the relationship between the two is mediated by the recommendations of the cardiologist and the attitude of the mother. Second, we argued that self-efficacy serves as a mediating variable between the recommendations of the cardiologist and the attitude of the mother, on the one hand, and involvement in physical activity, on the other. The results confirmed both hypotheses. In a population of adolescents with trivial to moderate congenital cardiac malformations, beliefs in self-efficacy, rather than severity of the disease, were the most influential factors in determining whether or not adolescents will engage in sports or other physical activities. We also demonstrated the importance of the role played by the recommendations of the cardiologist in determining both the attitudes of the mother and the belief in self-efficacy of the adolescents.

[Pulmonary involvement in Osler-Weber-Rendu syndrome].

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) is a group of autosomal dominant diseases with variable penetration, characterized by vascular malformations. Recently hereditary hemorrhagic telangiectasia has been found to be a phenotypic expression of mutations in genes located on chromosomes 9 and 12, and possibly of other genes located on other chromosomes. We describe 2 patients with hereditary hemorrhagic telangiectasia and pulmonary involvement who presented with repeated complaints of dyspnea and cyanosis and were diagnosed as having long-standing asthma. Both were treated with therapeutic catheterization and embolization with good clinical outcomes.

Use of the heart rate monitor to modulate physical activity in adolescents with congenital aortic stenosis: an innovative approach.

The task of setting exercise limitations on children with aortic stenosis is fraught with difficulties. In particular, teenagers are difficult to manage because of the increasingly professional demands of adolescents sports; the rapid changes in somatic growth, which are often accompanied by an increase in the severity of aortic valve disease; and the natural tendency of teenagers to disregard advice from authoritarian sources like a medical team. This article describes our innovative approach of using a heart-rate monitor as a means of modulating physical activity in adolescents with mild to moderate aortic stenosis. This approach enabled the setting of clear, precise, observable, measureable limits on physical activity, and self-controling of an acceptable level of physical activity. This created a different negotiation between the patient, his parents, and the medical team, and eased the concern and anxiety of the mothers.

Acute complications in the current era of therapeutic cardiac catheterization for congenital heart disease.

The acute complications of therapeutic cardiac catheterization for congenital heart disease as performed currently in a small unit were reviewed. In recent years, there has been a significant increase in the number of lesions thought amenable to catheter therapy. Only a few reports, however, have addressed the overall incidence of acute complications of therapeutic cardiac catheterization, all representing the experience of centres performing moderate-to-large numbers of procedures. A retrospective review was performed of 425 therapeutic catheter procedures performed at our institution between May 1993 and November 1997. Acute complications were retrieved from the database. This included all adverse events that were clinically recognized at the time of or within 2 weeks after the procedure and which, to the best of the authors' clinical judgement, were related to the catheterization and not part of the natural history of the child's illness. All patients were observed overnight following the procedure, and stayed in hospital if a complication developed. There were 49 acute complications (11.5%), of which 43 (10.1%) were deemed minor and 6 (1.4%) were considered major. The rate was low in patients with valvar pulmonary stenosis, including three neonates (3/45, 6.7%), for those undergoing angioplasty of native co-arctation (1/15, 6.7%) and pulmonary arteries (2/27, 7.4%); and for coil embolization of systemic to pulmonary collateral arteries (1/16, 6.3%). The rate was high in patients with valvar aortic stenosis, including 12 neonates (9/37, 24.3%), and for angioplasty of re-coarctation (4/23, 21.7%). There were more overall complications in neonates (25.6%) than in older patients (10.1%) (p < 0.01). Two patients died (0.5%), but no patient required emergency surgical intervention. In spite of the introduction of many new therapeutic modalities with greater intrinsic risk, and the fact that patients with more complex lesions and who are more acutely ill are being treated, the overall rate of complications remains relatively low. This probably reflects improvements in pericatheterization medical management, in selection of patients, in procedural techniques, and in the experience of operators.

A comparison of arterial versus venous-activated clotting time in patients with congenital heart disease undergoing cardiac catheterization.

Studies in adult patients undergoing percutaneous coronary angioplasty have demonstrated differences in measured activated clotting time (ACT) in venous vs. arterial blood samples. Ninety-two patients with congenital heart disease undergoing cardiac catheterization were prospectively evaluated to compare venous vs. arterial ACT values in monitoring heparin effect in this population. Simultaneous venous and arterial ACT samples were drawn at baseline, 10 min, 60 min, and every 30 min thereafter until each case was finished. ACT values were determined simultaneously with a dual-chambered Hemochron 801 instrument. At baseline and throughout the study up to 90 min, venous and arterial ACT values were not significantly different. They were also no different in the subgroup of cyanotic patients. Therefore, venous and arterial ACT values can be safely used alternatively to guide heparin dosing during cardiac catheterization in patients with congenital heart disease without the risk of undercoagulation.

[Percutaneous closure of patent arterial ducts with occluding spring coils].

In recent years percutaneous closure of small and medium-sized patent arterial ducts has been achieved using occluding spring coils. We describe our experience in 93 patients with this technique, using a snare to facilitate the procedure in most. All patients had a clinically apparent patent arterial duct and had undergone attempts at transcatheter closure at a mean age of 6.8 years. In 1, the duct was a residual lesion following surgical ligation, and in 5 it was a residual following attempted closure with the Rashkind double-umbrella. The mean narrowest diameter of the ducts was 2.1 mm. In our 93 patients implantation was successful in 92 (99%), using 1 coil (82 patients), or 2 (10 patients), and in 1 by a combination of a double-umbrella device and an occluding spring coil. The mean fluoroscopic screening time for the whole group was 22.8 minutes, which decreased to 16.8 minutes in the last 50 patients. The coil embolized in 7 patients, but was retrieved in 6 and the ducts were subsequently occluded with another coil. In 1 patient the coil was left in a distal small branch of the left pulmonary artery and the duct was successfully occluded with a double-umbrella. Color-Doppler echocardiogram performed the morning after placement of the coils showed residual leaks in 18%. At mean follow-up of 24.6 months repeat imaging showed residual leaks in only 3 of these patients (3%). We conclude that occlusion of small to medium-sized ducts using coils appears to be effective and is the treatment of choice. The use of a snare to hold and manipulate the coil as it is delivered improves control of the coil, the accuracy of its placement, as well as giving complete occlusion of the ducts.

[Balloon angioplasty of native coarctation of the aorta].

The use of balloon dilatation to treat native coarctation of the aorta is gaining acceptance among interventional pediatric cardiologists, but is still controversial. We describe our experience with this procedure in 21 children, mean age 5.6 years and mean weight 21.1 kg. Most had an additional congenital heart defect, most commonly a bicuspid aortic valve. 17 were asymptomatic, 3 had tachypnea and 1 infant had severe congestive heart failure and was ventilated. The mean systolic blood pressure was 129.7 mm Hg. Balloon dilatation was successful in 90% (19), decreasing the mean maximal systolic gradient from 35.3 to 9 mm Hg (p < 0.001), and increasing the narrowest area from 3.9 to 8.2 mm (p < 0.001), with a mean balloon-to-coarctation width-ratio of 2.8. There were no complications. Of 15 who underwent repeat cardiac catheterization at a mean interval of 10.6 months, 2 had a maximal systolic gradient of more than 20 mm Hg. 1 of these underwent successful repeat angioplasty and the other, who also had a small aneurysm, underwent surgical repair successfully. 2 others had small aneurysms and they are being followed clinically. All patients were seen again after a mean interval of 31 months. The mean systolic blood pressure was 104 mm Hg, significantly lower than before intervention (p < 0.002). 1 had an increased pressure gradient between right arm and leg of 35 mm Hg at later follow-up, and repeat cardiac catheterization demonstrated a good result 13 months after the initial procedure. She is awaiting a third catheterization. Overall, 90% had good mid-term results. Based on our experience and recent reports, balloon angioplasty is safe and effective in most children older than 7 months and should be considered a viable alternative to operation for discrete aortic coarctation. Further long-term evaluation is needed.

[1000 cardiac catheterizations in congenital heart disease].

Over the past 15 years, percutaneous therapeutic cardiac catheterization has become increasingly important in the treatment of congenital heart disease. We describe our experience in 1000 such catheterizations between 1993-1997. 55% were in 1-12-year-olds; only 20% were in patients younger than 1 year old and 11.3% were in adults with congenital heart defects. In about 50% it was at least a second cardiac catheterization. Overall, there were 425 therapeutic cardiac catheterizations, increasing from 33% in the first 200 procedures, to 63% in the last 200. We performed 30 different types of therapeutic catheterizations: 23.3% were valvular dilations, 21.4% vessel angioplasties, 36.9% closure procedures, 9.2% electrophysiological procedures, and 9.2% miscellaneous. In 31.3% of therapeutic catheterizations we used 12 new procedures. Minor complications occurred in 8.5% and major in 0.6%; most complications were successfully treated or were self-limited and there was no residual damage. In this report the current role of each type of major catheterization is discussed on the basis of our experience. Further development of technology for lesions not amenable to currently available transcatheter methods, and longer follow-up for current techniques will consolidate the role of therapeutic cardiac catheterization in congenital heart disease.

Interventional catheterization decreases plasma levels of atrial natriuretic peptide (ANP) in children with congenital heart defects.

Atrial natriuretic peptide (ANP) is one of the cardiac peptides implicated in volume and sodium homeostasis. We investigated the effect of interventional catheterization on plasma levels of ANP, aldosterone, and cortisol in 28 children with various congenital heart defects (CHD). Patients were divided by age into two groups: group A--infants and children over 3 months of age (n = 22), and group B--newborns (n = 6). These were compared to age-matched control groups. In group A, interventions included pulmonic valvotomy (n = 8), aortic valvotomy (n = 4), balloon angioplasty of native coarctation of the aorta (n = 3), balloon dilatation of the mitral valve (n = 1), and Rashkind double umbrella closure of patent ductus arteriosus (n = 6). Group B interventions included pulmonic valvotomy (n = 3), aortic valvotomy (n = 1), and balloon atrial septosomy (n = 2). In group A, mean ANP levels were markedly higher than in age-matched controls (125.2+/-15.8 vs. 24.6+/-4.6 pg/ml) (P <0.0001), and decreased immediately after intervention (75.6+/-11.4 pg/ml, P <0.02), and more markedly on follow-up (42.9+/-5.0 pg/ml, P < 0.0001). In group B (newborns), mean basal plasma levels were high before and after intervention and were not different from age-matched controls (243+/-42.1 vs. 220.8+/-16.2 pg/ml). There was a significant decrease on follow-up measurement (62.1+/-12.7 pg/ml, P < 0.005). In both groups, plasma cortisol levels increased significantly immediately following catheterization (P < 0.02), and normalized on follow-up. Basal aldosterone levels were normal in group A and high in Group B (9.9+/-3.8 vs. 167.6+/-16.9 ng/dl) (P < 0.001). It is suggested that plasma ANP levels are increased in children with CHD, without overt heart failure, and decrease significantly following successful intervention. In newborns with CHD, the physiological high ANP levels obscure the effect of the CHD.

[Transcatheter closure of atrial septal defect].

Isolated secundum atrial septal defect is one of the most common congenital heart defects. Surgical closure is the treatment of choice but is associated with a chest scar, some morbidity and a relatively long recovery and the use of cardiopulmonary bypass. Transcatheter closure of secundum atrial septal defect is therefore an attractive approach. 3 children, aged 5-10 years, underwent successful transcatheter closure of moderate to large central atrial septal defects with the Cardioseal device. The procedures were performed under x-ray and transesophageal echocardiographic guidance. Our initial experience, and that of others, indicates that transcatheter occlusion of secundum atrial septal defects is safe and effective and can be an appropriate alternative in approximately 60% of patients.

Midterm clinical impact versus procedural success of balloon angioplasty for pulmonary artery stenosis.

The objective of this study was to determine the procedural success rate of balloon angioplasty for branch pulmonary artery stenosis in terms of its clinical impact on the subsequent management of these patients. Most previous studies of balloon angioplasty have concentrated on the initial success rate (50-60%), complications (6-10%), recurrence rate ( approximately 15%), and technical issues. A favorable clinical impact was noted in only 35% of patients. Over a 3-year period (March 1990 to March 1993), 32 patients (17 boys, 15 girls) underwent 34 balloon angioplasty procedures. Their mean age at dilation was 7.6 +/- 4.3 years (range 1.1-19.0 years). Postoperative tetralogy of Fallot and tetralogy of Fallot with pulmonary atresia were the most frequent cardiac lesions (44%). The procedures were "technically" successful in 56% (19 of 34) of balloon dilations on the basis of at least two of the following criteria: an increase of >50% of the predilation diameter; an increase of >20% in the relative flow to the affected lung by radioisotope study; or a decrease in the systolic right ventricular/aortic pressure ratio from 85-100% to <60%. Twelve percent of the patients had transient complications (two deep vein thromboses, one unilateral pulmonary edema, and one pneumothorax). In 17 of 19 (89%) of the patients there was a favorable clinical impact on their subsequent care as based on one of the following criteria: resolution of the stenosis and avoidance of surgical intervention (n = 14); optimization of future surgical procedure (n = 3); reduction in right ventricular pressure to <60% of aortic pressure (n = 13). Five patients who had unsuccessful balloon angioplasty and one with initially successful balloon angioplasty later underwent endovascular stent placement, which also favorably influenced their clinical status. The success rate of balloon angioplasty for branch pulmonary artery stenosis, when measured by strict procedural criteria, is accompanied by a favorable clinical impact in more than 50% of patients. Hence this procedure should be the initial therapeutic modality in this setting despite the relatively high transient complication rate. The use of endovascular stents probably increases the favorable clinical impact.

Radiofrequency catheter ablation of ectopic atrial tachycardia.

Ectopic atrial tachycardia (EAT) is an uncommon type of supraventricular tachycardia. It is usually chronic, incessant and resistant to pharmacologic therapy. Radiofrequency catheter ablation, which has become one of the treatments of choice for the more common types of supraventricular tachycardia, has recently also been shown to be effective in EAT. Radiofrequency catheter ablation was attempted in three patients with incessant EAT. Two of the patients, aged 7 and 13 years, had signs of left ventricular dysfunction, and the EAT originated in the left atrium. The remaining patient, aged 72 years, had a right EAT with normal left ventricular function. Radiofrequency ablation was guided by endocardial atrial mapping to locate the site of earliest atrial activation. Ablation was successful in all three patients, with complete cure of the tachycardia for a follow-up period of 12 to 19 months. Radiofrequency catheter ablation of EAT is highly successful and should be considered as one of the treatments of choice for this arrhythmia.

Late death from aneurysm rupture following balloon angioplasty for branch pulmonary artery stenosis.

We report on a child with Williams syndrome who died from aneurysm rupture 2 weeks following balloon angioplasty for branch pulmonary artery stenosis.

Percutaneous closure of small patent ductus arteriosus: comparison of Rashkind double-umbrella device and occluding spring coils.

We compared our current practice of closing small patent ductus arteriosus (PDA) with coils with our previous experience of using double-umbrellas. Twelve patients underwent percutaneous closure of a small PDA with a coil. Selection criteria were a minimal diameter of < or = 2.5 mm and angiographic type A or E. The 12 most recent, non-consecutive patients who had undergone double-umbrella device closure of a PDA and would presently be considered suitable candidates for spring coil occlusion were retrospectively reviewed. The two groups were compared with regard to complications and immediate and midterm results. Eleven of the 12 attempted PDA occlusions using spring coils were successful. The mean follow-up period was 5.8 +/- 4.6 months. Color-Doppler echocardiograms have shown no residual leaks, no turbulence in the descending aorta, and no left pulmonary artery stenosis. All 12 attempted double-umbrella device placements were successful. The mean follow-up period was 16.2 +/- 5.8 months. Color-Doppler echocardiograms have shown trivial residual leaks in four patients and mild turbulent flow in the left pulmonary artery in one patient. There was no significant difference between the two groups in demographic and hemodynamic data. Although the mean follow-up time was significantly longer in the patients who underwent double-umbrella closure, there was significantly more color-Doppler echocardiographic evidence of residual flow (P < 0.03). Small PDA closure with coils is effective, resulting in less residual leaks compared with the double-umbrella device.

Total cavopulmonary connection (TCPC) for complicated congenital heart malformations.

We reviewed our experience with 40 patients who had undergone total cavopulmonary connection (TCPC) during the past three years. Thirty-one patients had functional single ventricle; only 8 of these with tricuspid atresia, five patients had complex forms of double outlet right ventricle (DORV), and four complex A-V canal. Previous palliative procedures, mostly systemic-pulmonic shunts, were performed in 34 patients. Concomitant procedures were required in 18 patients, mainly reconstruction of distorted pulmonary arteries. A subgroup of 14 high risk patients, that did not fulfil the classical Fontan criteria, underwent 4 mm fenestration of the intra-atrial baffle. There were three (7.5%) early postoperative deaths which occurred in the higher risk group (fenestrated group). However, the remaining patients were all in functional class I or II. Total cavopulmonary connection provides reasonably good definitive palliation for patients with single ventricle physiology. Fenestration of the intra-atrial baffle increases the number of candidates suitable for the Fontan procedure, although the exact inclusion criteria for these patients has yet to be defined.

Total cavopulmonary connection for complicated congenital heart malformations.

We reviewed our experience with 40 patients who had undergone total cavopulmonary connection during the past 3 years. Thirty-one patients had functional single ventricle, only 8 with tricuspid atresia; five had complex forms of double outlet right ventricle, and 4 complex A-V canal. Previous palliative procedures, mostly systemic-pulmonic shunts, were performed in 34 patients. Concomitant procedures, mainly reconstruction of distorted pulmonary arteries, were required in 18 patients. A subgroup of 14 high risk patients, who did not fulfil the classical Fontan criteria, underwent 4 mm fenestration of the intraatrial baffle. There were 3 (7.5%) early post-operative deaths that occurred in the higher risk group (fenestrated group). However, the remaining patients were all in functional class I or II. Total cavopulmonary connection provides reasonably good definitive palliation for patients with single ventricle physiology. Fenestration of the intraatrial baffle increases the number of candidates suitable for the Fontan procedure, although the exact inclusion criteria for these patients has yet to be defined.