Pediatrics – ABC CARDIOL

ABCHF

Viewpoint

What We Choose to Fund Defines Who We Choose to Save: Pediatric Heart Failure in Emerging Economies

Carolina Vieira de Campos et al. Luiz Fernando Caneo Tamara J. Pimenta Desiree S. Machado

Management of pediatric advanced heart failure (HF) in low- to middle-income countries faces substantial and interconnected challenges, including severely limited access to specialized care, a shortage of adequately trained healthcare professionals, delayed referrals, and high mortality rates. These systemic constraints significantly restrict both the availability and the effectiveness of life-saving therapies for children with end-stage HF.

A deeper understanding of mechanical circulatory support (MCS) in emerging economies – illustrated here through the Brazilian experience – provides a valuable foundation for identifying structural, logistical, and ethical barriers to care. Such analysis also informs the development of strategies aimed at the sustainable and equitable expansion of advanced HF therapies for children.

[…]

Read Full Article

ABC

Editorial

The New Frontier of Point-of-Care Ultrasound: Lung Ultrasound in Congenital Heart Disease

Maria Estefânia Bosco Otto

The bedside assessment of pulmonary congestion is undergoing conceptual consolidation: lung ultrasound (LUS) has evolved from being merely an “adjunct” tool to assuming a central role in the identification of extravascular fluid and aeration patterns, with important diagnostic, prognostic, and therapeutic implications. The article by Donmez et al. directly discusses the role of LUS in the assessment of pulmonary edema in children with congenital heart disease (CHD). In a retrospective cohort of 62 children, the study observed pulmonary edema in 53% by LUS and in 58% by radiography. Furthermore, the presence of edema by LUS was associated with clinically relevant variables in the clinical picture, such as recurrent respiratory infections, low weight, and elevated BNP levels. These findings reinforce that LUS adds objective and reproducible information to the care of children, in a context where clinical examination can be hampered by low cooperation and bedside radiography may have reduced accuracy due to positioning limitations and technical quality.

In adults with heart failure, the usefulness of LUS for pulmonary congestion is supported by several clinical studies demonstrating high diagnostic performance and correlation with outcomes. B-lines reflect increased extravascular fluid and, when diffusely present, reclassify the differential diagnosis of dyspnea. Comparison between LUS, biomarkers, and clinical assessment in an outpatient setting has shown that the burden of B-lines can detect subclinical congestion and anticipate the possibility of decompensation.^, In an acute setting, the systematic implementation of LUS improves diagnostic accuracy for decompensated heart failure, and prognostic studies associate congestion detected by LUS with worse short- and long-term outcomes. Reviews and perspective papers in cardiology have highlighted LUS as a rapid, reproducible, and low-cost diagnostic modality.

[…]

Read Full Article

IJCS

Editorial

Education and Training in Pediatric Cardiac Critical Care: An Essential Tool to Improve Outcomes

Klebia Castello Branco et al. Jorge Yussef Afiune

In an article published in the International Journal of Cardiovascular Sciences, Campos and Carvalho examine the challenges of educating and training teams in pediatric cardiac critical care in developing countries. They also highlight emerging opportunities for improvement and growth.

In recent decades, substantial advances have been made in the field of pediatric cardiology, including progress in pediatric cardiac surgery, catheter-based interventions, anesthesia, cardiac imaging and monitoring, neonatal and pediatric critical care, mechanical circulatory support, and the expansion of multidisciplinary teams. These advances have led to significant improvements in outcomes for children with congenital and acquired heart disease. However, congenital heart disease still places a significant burden on health care systems, especially in low- and middle-income countries.

[…]

Read Full Article

IJCS

Original Article

Childhood Obesity and Systemic Arterial Hypertension in Children and Adolescents: A Cross-Sectional Study

Rafaella Farias da Franca Almeida et al. Lívia Menezes Escorel Letícia Odete Guedes de Andrade Carvalho Camila Batista Gaudêncio … Lara Ataide Diniz Marcela Leite Marina Romero Costa Alice Barbosa Maia Berenice Lempek dos Santos Michelle Barros de Aguiar Patrícia Vidal de Negreiros Nóbrega Eugênia Moreira Fernandes Montenegro Débora Alencar de Menezes Athayde Jessica Laureano Martins

Abstract

Background:

The increase in obesity cases and the lack of screening and diagnosis of childhood hypertension highlight the need to examine these comorbidities in children.

Objectives:

To investigate the relationships between systemic arterial hypertension (SAH) and childhood obesity (CO) in pediatrics and correlate the obesity level, abdominal circumference (AC), family history, and physical activity (PA) variables.

Methods:

This cross-sectional study assessed age, sex, height, weight, body mass index (BMI), AC, family history, PA, CO, and blood pressure (BP) percentiles. The Chi-square test, Fisher’s Exact test, and Spearman’s correlation were used for data analysis, with a statistical significance level of 5%.

Results:

After applying the inclusion and exclusion criteria, 30 patients aged between 3 and 18 years (incomplete) were evaluated at three different moments. The results showed that 83.3% (n = 25) of the patients were obese and 16.70% (n = 5) had severe obesity. Among them, 20% (n = 6) were diagnosed with SAH. Data showed an independence between CO and SAH (p = 0.702) and between SAH and PA time (p = 0.748). No correlations were observed between SAH and AC (p = 0.313). The history of SAH in first-degree relatives was significantly associated with the diagnosis of SAH (p = 0.004).

Conclusion:

This study showed no correlation between CO and SAH in the evaluated sample, supporting the need for further research in the area.

Read Full Article

ABCIC

Editorial

Emerging Topics in Pediatric Echocardiography: A Review by the Associate Editors of the Pediatric Section

Karen Saori Shiraishi Sawamura et al. Márcio Miranda Brito

Ventricular septal morphology and cardiac development

Anderson et al. convened international experts to propose a unified morphofunctional classification of ventricular septal defects, with emphasis on embryological features and ventriculoarterial connections. The authors critically examine the nomenclature currently in use and suggest that defect descriptions should encompass both their anatomical location and the borders involved. This approach integrates principles of cardiac development and allows, for example, differentiation between perimembranous defects in hearts with double outlet right ventricle and those with concordant ventriculoarterial connections. The article provides a clear and didactic review of cardiac embryological development, supported by illustrations that facilitate a more precise diagnostic and surgical approach.

[…]

Read Full Article

ABC

Editorial

Images Complement Words: Absence of Progression of Myocardial and Coronary Artery Injury in School-Age Children Undergoing Radiofrequency Catheter Ablation

Jorge Elias Neto et al. Márcio Augusto Silva

Not even the biggest enthusiasts among cardiologists could predict, at the end of the 1980s, the impact that catheter ablation would have on the treatment of cardiac arrhythmias. Since its advent, evidence, and clinical experience have accumulated that allow to affirm its effectiveness in the treatment of the most varied forms of cardiac tachyarrhythmias in individuals of all age groups.^–

Particularly in the pediatric population, these perspectives have gradually shifted from the use of catheter ablation only in cases of drug-refractory arrhythmia to a first-line treatment and patient/parent preference.^,- However, this generalization raises the question of whether it is appropriate to adopt a technique into clinical practice in the absence of animal or human data that sufficiently demonstrates both its safety and efficacy in immature organs.^,

[…]

Read Full Article

IJCS

Editorial

Can D-dimer be Used as a Marker for Thromboembolic Events in Pediatric Patients With COVID-19?

Thais Rocha Salim et al. Gabriel Porto Soares

D-dimer is a protein resulting from fibrin degradation. It is released into the circulation when clot degradation occurs and is therefore used as a marker for thromboembolic events and fibrinolysis. The main role of D-dimer lies in its negative predictive value for the exclusion of thromboembolic events, when its level is below 500 ng/mL. Because D-dimer functions as an inflammatory marker, various non-thromboembolic situations can contribute to an increase in its level, such as advanced age, pregnancy, postpartum period, neoplasms, renal insufficiency, and sepsis. Age is a crucial factor when considering D-dimer a thromboembolic marker. Healthy populations over 70 years of age have shown a 50% increase in D-dimer levels without correlation with thrombotic or inflammatory events.

During the COVID-19 pandemic, several studies have demonstrated a positive correlation of elevated D-dimer levels, prolonged coagulation time, and low platelet count with mortality from COVID-19.^,,,Although D-dimers lack high specificity as a diagnostic tool, they have been widely used as predictors of severity and complications in this setting, given that D-dimer tests are rapid, simple, and low-cost.^– However, hyperinflammation caused by SARS-CoV-2 infection can lead to an increase in D-dimer unrelated to thrombosis, which implies its correlation with other tests and caution in interpreting the results.

[…]

Read Full Article

ABCIC

Case Report

Expandable Airway Stents: Success in the Extrinsic Bronchial Compression Approach After Reconstruction of the Aortic Arch

Camila Magalhães Silva et al. Adriana Furletti Machado Guimarães Ricardo Wang Carla Maria Silva e Alves Edmundo Clarindo Oliveira

Introduction

The interruption of the aortic arch is a rare congenital cardiopathy, whose surgical correction generally requires reconstruction of the aortic arch. This intervention can cause distortion of the aortopulmonary space and results in bronchial compression with a consequent pulmonary atelectasis and dependence on ventilatory assistance. The most commonly used therapeutic options for bronchial decompression are not always enough to make pulmonary expansion possible. Our study presents a case of the implant of an endoluminal stent in an infant who, in the post-operative stage of the correction of the interruption of the aortic arch, developed complete atelectasis of the left lung secondary to bronchial compression, with no response after posterior aortopexy

[…]

Read Full Article

ABCIC

Case Report

Importance of Echocardiography in the Differential Diagnosis of Rheumatic Mitral Regurgitation in Children and Adolescents

Camila Magalhães Silva et al. Maik Arantes Fátima Derlene da Rocha Araújo Adriana Furletti Machado Guimarães Zilda Maria Alves Meira

Introduction

Mitral regurgitation (MR) can be a result of abnormalities in different locations of the valve apparatus (cusps, annulus, tendinous cords and papillary muscles), being of acquired or congenital etiology. MR can be classified as primary, when resulting from a deformity in the valve structure, or secondary, when related to another heart or systemic disease. In our field, the main cause of MR in students and adolescents is the acquired one. Rheumatic fever (RF) is among the causes, as well as bacterial endocarditis, which should be considered in the differential diagnosis.^, However, congenital anomalies, such as mitral valve (MV) prolapse, mitral cleft (MC), parachute MV and, rarely, isolated cleft MV (ICMV) should be ruled out.^, The etiological diagnosis of MR is very important to determine the proper treatment, once it can be clinical or surgical, with definitive correction of the lesion.

We present the report of a student whose clinical and echocardiographic scenario was first diagnosed as acute RF, showing the importance of echocardiography in the posterior differential diagnosis of MR.

[…]

Read Full Article

ABCIC

Review Article

My Approach to the Echocardiographic Assessment of a Pediatric Patient with Cancer

Claudia Cosentino Gallafrio et al. Ricardo H. Pignatelli

What is the importance of cardiovascular assessments in pediatric patients with cancer?

Pediatric oncology has greatly progressed in recent decades due to the development of more effective treatment protocols; in fact, 5-year disease-free survival rates now exceed 80%. However, despite improved survival rates, the cardiovascular risks arising from these therapies are 5- to 6-fold greater in long-term surviving oncology patients than the general pediatric population.^, Thus, cardiovascular events, such as myocardial infarction, heart failure, and stroke, are the major cause of non-cancer death in these patients.

Cardiotoxicity is defined as any structural or functional damage incurred by the heart and circulation during or after cancer treatment. These changes may be caused by chemotherapeutic agents, radiotherapy, or even the disease itself (). Cardiotoxicity may present as symptomatic or asymptomatic heart failure, pericardial changes, arrhythmias, thromboembolic events, arterial hypertension, or valve and coronary diseases^, and can be classified by time of onset as follows:

[…]

Read Full Article

ABC

Editorial

The Electrocardiogram in the Pediatric Population in the 21st Century. How to Keep Evolving after 135 Years of the Method Discovery History

Rogerio Braga Andalaft

Knowledge of the electrocardiogram remains constantly evolving in medical practice. The new interfaces for electrocardiogram (ECG) correlation with cardiac images and heart functional changes increase the method’s applicability. However, in children and adolescents, the constant change generated by these young people’s body and functional development often generates doubts in the interpretation of electrocardiographic tracings, even in the most experienced professionals. Recently, important data on ECG interpretation were extensively reviewed in the IV Guidelines of the Sociedade Brasileira de Cardiologia on Analysis and Issuance of Electrocardiographic Reports published in 2022.

But what is the role of the electrocardiogram, especially applied to pediatrics, in the 21^st century? What is normal for the child? What is the prevalence of electrocardiogram changes in asymptomatic patients?

[…]

Read Full Article

ABCIC

Special Article

Pediatric Cardiac Tumors: Echocardiographic Imaging Features

Nathalie Jeanne Magioli Bravo-Valenzuela et al. Eliane Lucas Nadinne Velloso Netto Larissa Vieira da Conceição … Natalia Pinheiro Duque Estrada Maria Respondek-Liberska Edward Araujo Júnior

Abstract

Cardiac tumors (CTs) in children are very rare, but their diagnosis is crucial for patient management. Echocardiography is the most commonly used cardiovascular imaging modality in clinical practice for the initial diagnosis of CTs in pediatric patients. Knowing the echocardiographic characteristics of CTs can enable an increasingly early diagnosis and the identification of its most likely etiology. Primary and benign CTs are the most frequent types in the pediatric population. Among benign CTs, the most frequent in fetuses and neonates are rhabdomyomas and teratomas. In children and adolescents, rhabdomyomas and fibromas are more common. Here we describe the echocardiographic characteristics of the most common CTs in pediatric patients.

Read Full Article

ABCIC

Original Article

Echocardiography: The Examination Request by the Pediatriciant Achieving the Pediatric Cardiologist

Lene Garcia Barbosa et al. Amanda Bentes Rios de Freitas Mariana Aparecida Brunossi Moura Proença Célia Maria Camelo Silva

Summary

Background

Echocardiography is a diagnostic tool used to evaluate cardiac anomalies and clarify doubts about the benign nature of certain findings of cardiovascular clinical examination.

Objectives

To identify the main reasons for the request of echocardiography by pediatrician and evaluate the degree of anxiety of the family generated by this conduct.

Methods

We included patients younger than 18 years without previous diagnosis of heart disease and referred for the first echocardiogram. Family members responsible for the patients answered a questionnaire to assess the degree of their anxiety from order to the performance of the echocardiogram, with scores between 0 and 19. Data were analyzed using percentages, standard deviation and Student’s t test.

Results

Studied 30 patients with a mean age of 4.45 years. The most prevalent reason for referral was heart murmur (23 cases), of which 70% patients had no congenital heart disease hypothesis confirmed, after echocardiography. The average score on the anxiety questionnaire was 11 ± 6 significantly associated with the presence of heart disease, with a mean of 13.0 ± 5.3 vs. 9.3 ± 5.2 in the group without the possibility of it (p = 0.007).

Conclusion

The murmurs findings was the main reason for echocardiography request by the pediatrician. Confirmation of heart disease was higher in children under 1 year and with murmurs findings. Despite the anxiety level was higher in the group of patients who were diagnosed with congenital heart disease, this was not negligible in the family in the group of patients without heart disease. (Arq Bras Cardiol: Imagem cardiovasc. 2017;30(2):39-45)

Read Full Article

ABCIC

Editorial

Applications of Myocardial Strain Study Using Two-Dimensional Speckle-Tracking in Pediatrics

Laura Mercer-Rosa

[…]

Read Full Article

ABCIC

Review Article

Echocardiographic Evaluation of Pulmonary Hypertension in Children

Karen Saori Shiraishi Sawamura et al. Alessandro Cavalcanti Lianza Gabriela Nunes Leal Samira Saady Morhy

Abstract

Hypertensive Pulmonary Disease (HPD) can be defined as a set of pathophysiological pulmonary disorders that result in severe, progressive disease with high morbidity and mortality. Transthoracic echocardiogram (TTE) is an easily accessible and essential imaging method for the evaluation of this disease, especially in children, where there are limitations to frequent and routine right-heart catheterization. In this review, we address the main echocardiographic techniques for the diagnosis and hemodynamic evaluation of pulmonary hypertension in the pediatric population. Early diagnosis and appropriate staging in the follow-up of clinical interventions are fundamental for the assertive choice of therapeutic approach and, consequently, improvement of clinical outcomes.

Read Full Article

ABCIC

Original Article

Non-Compacted Cardiomyopathy in Children and Adolescents: From the Challenge of Echocardiographic Diagnosis to Clinical Follow-Up

Ana Flávia Malheiros Torbey et al. Ana Catarina Durán Bustamante Aurea Lucia Grippa de Souza Carmen Zampirole Brandão … Luan Rodrigues Abdallah Yves Pacheco Dias March e Souza Evandro Tinoco Mesquita

Abstract

Background

Non-compacted cardiomyopathy (NCCM) is characterized by hypertrabeculations and deep recesses in the left ventricle, with a heterogeneous clinical presentation, ranging from asymptomatic patients to those with heart failure (HF), thromboembolic events and arrhythmias with risk of sudden death. As it is rare and does not have well-defined diagnostic criteria, its natural history in pediatrics is poorly understood. This study describes the clinical presentation and clinical course of patients with NCCM.

Methodology

Observational, longitudinal, prospective study of pediatric patients seen at a pediatric cardiology referral center from metropolitan region II in the state of Rio de Janeiro, with NCCM phenotype on echocardiogram (ECHO) during a 2-year follow-up, from the ChARisMa registry.

Results

6 patients aged 4 to 14, with NCCM, were analyzed. Mean age 7.5 years (SD: 3.93), 3 males (50%). The patients presented HF (n=2), cardiac murmur (n=1), cardiac arrhythmia (n=1), were asymptomatic (n=1) or were under investigation for a genetic syndrome (n=1). Phenotypes on ECHO: NCCM/dilated cardiomyopathy (n=1) and NCCM/restrictive cardiomyopathy (n=1), isolated phenotype of NCCM (n=4). Cardiac magnetic resonance imaging was performed and confirmed the diagnosis (n=4). The outcomes observed were thromboembolism, indication for heart transplantation, and sustained ventricular tachycardia.

Conclusions

This case series provides relevant data for pediatric NCCM as it shows its heterogeneous clinical presentation and potentially fatal complications. More prospective studies are needed for an accurate diagnosis and to allow its clinical course, therapeutic response and prognosis to be better known.

Read Full Article

ABC

Original Article

Current Use of Pediatric Cardiac Magnetic Resonance Imaging in Brazil

Marcelo Felipe Kozak et al. Jorge Yussef Afiune Lars Grosse-Wortmann

Abstract

Background

Data on the use of cardiac magnetic resonance imaging (CMR) on children in Brazil is lacking.

Objectives

This study sought to provide information on current pediatric CMR practices in Brazil.

Methods

A questionnaire was sent out to referring physicians around the country. It covered information on the respondents, their CMR practices, the clinical context of the patients, and barriers to CMR use among children. For statistical analysis, two-sided p < 0.05 was considered significant.

Results

The survey received 142 replies. CMR was reported to be available to 79% of the respondents, of whom, 52% rarely or never use CMR. The most common indications were found to be cardiomyopathies (84%), status of post-tetralogy of Fallot repair (81%), and aortic arch malformations (53%). Exam complexity correlated with CMR-to-surgery ratio (Rho = 0.48, 95% CI = 0.32-0.62, p < 0.0001) and with the number of CMR exams (Rho = 0.52, 95% CI = 0.38-0.64, p < 0.0001). Further, a high CMR complexity score was associated with pediatric cardiologists conducting the exams (OR 2.14, 95% CI 1.2-3.89, p < 0.01). The main barriers to a more frequent use of CMR were its high cost (65%), the need for sedation (60%), and an insufficient number of qualified professionals (55%).

Conclusion

Pediatric CMR is not used frequently in Brazil. The presence of a pediatric cardiologist who can perform CMR exams is associated with CMR use on more complex patients. Training pediatric CMR specialists and educating referring providers are important steps toward a broader use of CMR in Brazil. (Arq Bras Cardiol. 2021; 116(2):305-312)

Read Full Article