Search

Congenital right ventricular aneurysms and diverticula are rare congenital anomalies and prenatal detection is uncommon. Distinguishing between these two anomalies by imaging alone is difficult. Recently, we were asked to review a 21-week ultrasound that detected an “extra cardiac chamber.” This represents the first report of an isolated out-pouching of the right ventricular free wall to be detected by prenatal screening ultrasound. Based on preoperative imaging, this out-pouching was diagnosed as a ventricular aneurysm, but intraoperative findings suggested it was a diverticulum. This case will review the differences between ventricular aneurysms and diverticula and illustrate the use and limitations of various imaging modalities used in their evaluation, both prenatally and postnatally. A plan of management is suggested.

Background Group A streptococcus (GAS) causes illness ranging from uncomplicated pharyngitis to life-threatening necrotizing fasciitis, toxic shock, and rheumatic fever. Attempts to develop an M protein-based vaccine have been hindered by the fact that some M proteins elicit both protective antibodies and antibodies that cross-react with human tissues. New molecular techniques have allowed the previous obstacles to be largely overcome. Methods The vaccine is comprised of 4 recombinant proteins adsorbed to aluminum hydroxide that contain N-terminal peptides from streptococcal protective antigen and M proteins of 26 common pharyngitis, invasive, and/or rheumatogenic serotypes. Thirty healthy adult subjects received intramuscular 26-valent GAS vaccine (400 microg) at 0, 1, and 4 months, with clinical and laboratory follow-up for safety and immunogenicity using assays for tissue cross-reactive antibodies, type-specific M antibodies to 27 vaccine antigens, and functional (opsonization) activity of M protein antibodies. Results The incidence of local reactogenicity was similar to that for other aluminum hydroxide-adsorbed vaccines in adults. No subject developed evidence of rheumatogenicity or nephritogenicity, and no induction of human tissue-reactive antibodies was detected. Overall, 26 of 27 antigenic peptides evoked a >4-fold increase in the geometric mean antibody titer over baseline. The mean log2 fold-increase in serum antibody titer (+/- standard error of the mean) for all 27 antigens was 3.67 +/- 0.21. A significant mean log2 reduction in streptococcal bacterial counts in serum samples obtained after immunization was seen in opsonization assays for all M serotypes. Conclusions On the basis of epidemiological data demonstrating that the majority of cases of pharyngitis, necrotizing fasciitis, and other invasive streptococcal infections are caused by a limited number of serotypes, this 26-valent vaccine could have significant impact on the overall burden of streptococcal disease.

Streptococcal endocarditis in an infant is rare. We report a case of acute aortic valve endocarditis with abscess and aorta-to-right atrial fistula formation. This 4-month-old infant with a structurally normal heart had been previously well. The child was successfully treated with the Ross procedure and remains well 13 months postoperatively.

Transesophageal echocardiography in an asymptomatic nine-month-old girl discerned features of an inferior sinus venosus defect, demonstrating left-to-right shunting across a posteroinferior interatrial connection (Figures 1A and 1B) near the inferior vena cava, and a small, separate patent foramen ovale (Figure 1C). The right inferior pulmonary vein entered the left atrium more obliquely than normal, and the right atrium and right ventricle were slightly dilated. The diagnosis was confirmed intraoperatively during subsequent elective pericardial patch repair: the defect was located outside the intact muscular limbus, unrelated to the oval fossa and patent foramen ovale (Figure 2), and was bounded inferiorly by an overriding inferior vena cava. These features, with or without anomalous pulmonary venous drainage, distinguish this rare congenital defect from posterior defects of the atrial septum (1,2). Figure 1 Transesophageal echocardiography showing a posteroinferior interatrial connection (arrow) near the inferior vena cava (IVC) (A and B), and a small, separate patent foramen ovale (arrowhead) (C). LA Left atrium; RA Right atrium; RIPV Right inferior pulmonary ... Figure 2 Transesophageal echocardiography showing an intact muscular limbus (arrow) unrelated to the oval fossa and patent foramen ovale (arrowhead). IVC Inferior vena cava

Regulatory decisions and scientific statements regarding the management of attention-deficit hyperactivity disorder (ADHD) raise questions about the safety of medications and the appropriate pretreatment evaluation to determine suitability for treatment with medication. This is particularly true in the setting of known structural or functional heart disease. The present paper reviews the available data, including peer-reviewed literature, data from the United States Food and Drug Administration Web site on reported adverse reactions in children using stimulant medication, and Health Canada data on the same problem. A consensus-based guideline on appropriate assessment is provided, based on input from members of the Canadian Paediatric Society, the Canadian Cardiovascular Society and the Canadian Academy of Child and Adolescent Psychiatry, with specific expertise and knowledge in the areas of both ADHD and pediatric cardiology. The present statement advocates a thorough history and physical examination before starting stimulant medications, with an emphasis on the identification of risk factors for sudden death, but does not routinely recommend electrocardiographic screening or cardiac subspecialist consultation unless indicated by history or physical examination findings. A checklist for identifying children who are potentially at risk of sudden death (independent of ADHD or medications used to treat it) is provided. Although recommendations are based on the best evidence currently available, the committee further agrees that more research on this subject is necessary to optimize the approach to this common clinical scenario.

Regulatory decisions and scientific statements regarding the management of attention-deficit hyperactivity disorder (ADHD) raise questions about the safety of medications and the appropriate pretreatment evaluation to determine suitability for treatment with medication. This is particularly true in the setting of known structural or functional heart disease. The present paper reviews the available data, including peer-reviewed literature, data from the United States Food and Drug Administration Web site on reported adverse reactions in children using stimulant medication, and Health Canada data on the same problem. A consensus-based guideline on appropriate assessment is provided, based on input from members of the Canadian Paediatric Society, the Canadian Cardiovascular Society and the Canadian Academy of Child and Adolescent Psychiatry, with specific expertise and knowledge in the areas of both ADHD and paediatric cardiology. The present statement advocates a thorough history and physical examination before starting stimulant medications, with an emphasis on the identification of risk factors for sudden death, but does not routinely recommend electrocardiographic screening or cardiac sub-specialist consultation unless indicated by history or physical examination findings. A checklist for identifying children who are potentially at risk of sudden death (independent of ADHD or medications used to treat it) is provided. Although recommendations are based on the best evidence currently available, the committee further agrees that more research on this subject is necessary to optimize the approach to this common clinical scenario.