|Year : 2016 | Volume
| Issue : 2 | Page : 130-135
The spectrum of structural heart defects seen in children at the University College Hospital, Ibadan
Bosede E Adebayo1, Oluwatoyin O Ogunkunle1, Samuel I Omokhodion1, Ronita D Luke2
1 Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria
2 Department of Paediatrics, University College Hospital, Ibadan, Nigeria
|Date of Web Publication||4-Aug-2016|
Oluwatoyin O Ogunkunle
Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan
Source of Support: None, Conflict of Interest: None
Background: Structural heart defects constitute one of the commonest reasons for Paediatric Cardiology consultations. The availability of echocardiography has obviated the need for invasive procedures in providing an accurate diagnosis and description in such children.
Objective: To describe the pattern of congenital and acquired heart diseases seen in children referred to the Paediatric Cardiology Clinic of the University College Hospital, Ibadan
Methods: Consecutive cases referred to the Paediatric Cardiology Clinic over a twelve-month period were evaluated by clinical examination, chest x-ray, electrocardiography and echocardiography. Data were analysed using SPSS for Windows software, version 20.0. Frequency distributions were generated and the Wilcoxon signed rank test was used to test the association between the age at onset of symptoms and the age at presentation. Level of significance was set at P < 0.05
Results: Two hundred and forty children underwent echocardiography; 80.4% were aged 5 years and below. Structural heart defects were encountered in 210 (87.5%) children. Congenital defects comprised 80% of the cases, the commonest being VSD, occurring either singly (24.1%) or in combination with other defects in 18.7%. The commonest cyanotic lesion, Fallot's Tetralogy (9.2%) occurred more commonly than other isolated acyanotic lesions. Acquired heart disease accounted for 7.5% of cases, dilated cardiomyopathy, rheumatic heart disease, and pericardial effusion (occurring in 2.9%, 2.5% and 2.1% respectively). The median age at presentation (13 months) was significantly higher than that at onset of symptoms (11 months) (P = <0.001).
Conclusions: Ventricular septal defect remains the commonest structural defect seen in our centre. Fallot's Tetralogy however is more common than isolated patent ductus arteriosus or atrial septal defect. Dilated cardiomyopathy and RHD are equally common.
Keywords: Children, echocardiography, Nigeria, structural heart defects, Sub-Saharan Africa
|How to cite this article:|
Adebayo BE, Ogunkunle OO, Omokhodion SI, Luke RD. The spectrum of structural heart defects seen in children at the University College Hospital, Ibadan. Nig J Cardiol 2016;13:130-5
|How to cite this URL:|
Adebayo BE, Ogunkunle OO, Omokhodion SI, Luke RD. The spectrum of structural heart defects seen in children at the University College Hospital, Ibadan. Nig J Cardiol [serial online] 2016 [cited 2019 Jun 17];13:130-5. Available from: http://www.nigjcardiol.org/text.asp?2016/13/2/130/187712
| Introduction|| |
Congenital heart diseases (CHD) constitute the greater percentage of the burden of cardiac diseases in children worldwide. [1-4] The prevalence of congenital heart diseases in reported studies is 4-10 per 1000 live births. [4-6] Most reported studies in Africa have profiled either congenital heart diseases or acquired heart diseases as single entities. [7-9] Although acquired heart diseases constitute a smaller percentage of heart disease in children, they are frequent in Nigeria. Over the decades, the pattern of cardiac diseases in children has reflected evolving changes, which might be adduced among other factors, to the advent and increasing availability of echocardiography as a diagnostic tool.
Gupta and Antia  gave one of the earliest reports of the spectrum of congenital heart diseases in sub-Saharan Africa about five decades ago. Their report was however based on clinical and autopsy findings in the newborn. Jaiyesimi and Antia  , a decade later based on the high rate of autopsies as well as the availability of cardiac catheterization and surgical intervention resulting in better diagnostic precision, gave a subsequent report of the spectrum of congenital heart diseases seen in the Cardiology Clinic of the University College Hospital, Ibadan. The advent of echocardiographic studies in this referral institution in South-western Nigeria has made diagnostic precision not only available but also easier with much less hazards. There is a need therefore, to re-appraise the spectrum, not only of congenital heart diseases, but also acquired heart diseases in the light of the availability of echocardiography. It is also important to document the spectrum of structural heart defects seen in this environment to observe any environmental or regional difference if such exists. Echocardiography provides an opportunity not only for non-invasive diagnostic evaluation, but also real time results and interpretations and an opportunity for repeated reviews and monitoring.
This cross-sectional study was undertaken to describe the pattern of congenital and acquired heart disease occurring in children referred to the Paediatric Cardiology Clinic of the University College Hospital, Ibadan
| Materials and methods|| |
A cross sectional descriptive study was carried out in the Paediatric Cardiology unit of the University College Hospital, Ibadan over a period of 12 months, from August 2012-July 2013.
The new patients referred to the Paediatric Cardiology clinic, which runs once a week, were the subjects of this study. All patients were evaluated clinically by a Paediatric Cardiologist. A detailed history and clinical assessment was undertaken to obtain the name, age, gender, age at onset of illness, symptoms, previous hospital admissions, pregnancy, birth, neonatal and family history. A detailed general examination was also performed to observe for weight for age, pallor, cyanosis, plethora, digital clubbing, pedal oedema and dysmorphic features. A detailed cardiovascular examination was done which included palpation of the radial (bilateral) and femoral pulses, assessment of the praecordium and localisation of the apex beat. The heart sounds were assessed and the presence and timing of the murmurs determined when present. The respiratory, abdomen and central nervous systems were also examined.
At the first visit, a chest radiograph, 12 lead electrocardiogram (ECG) and echocardiogram were performed to arrive at a definitive diagnosis. ECG was performed using a 12-channel resting electrocardiogram by QRS diagnostics. The chest leads and the limb leads were placed on the children using paediatric electrodes. The recordings were then viewed and necessary corrections in lead placement made. Records free of artefacts were printed for review.
Echocardiography was performed by either or both of O.O.O and B.E.A, (both Paediatric Cardiologists, experienced in paediatric echocardiography), using a Toshiba Xario XG and a 3.5 MHz sector probe. Patients less than three years of age were sedated using 50mg/kg of chloral hydrate. Standard views were obtained in accordance with the American Society of Echocardiography guidelines for performing paediatric echocardiograms  and a diagnosis assigned after these views had been assessed and occasionally re-assessed for establishment of the diagnosis. Rheumatic heart disease was diagnosed based on the World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease in individuals aged ≤20 years.  Diagnosis of dilated cardiomyopathy was made in children with primary myocardial disease characterized by varying degrees of left ventricular dysfunction and dilatation in the absence of increased afterload or volume overload. 
Parents of children with abnormalities were counselled and the children referred to appropriate centres for surgical intervention as necessary.
Data were entered into a computer using the SPSS for Windows software, version 20.0. The data was analysed after ensuring proper entry and subsequent cleaning. The various frequency distributions were then run. The Wilcoxon signed rank test was used to test the association between the age at onset of symptoms and the age at presentation of structural cardiac defects. The level of significance was set at P < 0.05.
| Results|| |
A total of two hundred and forty new patients were seen in the Paediatric Cardiac Outpatient clinic during this period. Ninety-six (40%) of the children were referred on suspicion of a structural cardiac anomaly based on the presence of symptoms/signs referable to the cardiovascular system. Ninety-six (40%) were referred from other specialist clinics in our centre for routine cardiac evaluation on suspicion of a syndromic condition such as Trisomy 21, or following the identification of other congenital anomalies, which included congenital cataracts, glaucoma, gastrointestinal anomalies and vertebral anomalies. The others were referred for pre-operative evaluations for various surgical procedures and not based on any symptoms.
A total of 240 children aged between 1 week and 14 years had echocardiographic evaluation during the period. The male to female ratio was 1.7:1. Eighty percent of the children were aged 5 years and below. [Table 1] shows the age and gender distribution of the children.
A statistically significant difference was observed between the ages at onset of symptoms and presentation, such that the median age at presentation (13 months) was significantly higher than that of the onset of symptoms (11 months) with some children presenting as late as six months after the onset of symptoms. (Wilcoxon signed rank test, P = < 0.001). None of the cases of congenital heart diseases had a prenatal diagnosis although all the mothers had benefitted from ultrasound scans in pregnancy.
[Table 2] shows the echocardiography findings in the 240 children and [Table 3] shows the pattern of congenital heart diseases in the children.
|Table 2: Echocardiography results in the 240 children with suspected heart defects |
Click here to view
Two hundred and ten (87.5%) of the patients had structural heart defects, while thirty (12.5%) had structurally normal hearts. The most frequent heart defects were congenital heart defects comprising 80% of the cases, the most common being VSD [Figure 1]. Ten children with Trisomy 21 had ASDs [Figure 2], VSDs or a combination of both lesions. The 9 cases of atrioventricular canal defect [Figure 3] all occurred in children with Trisomy 21. One child with Trisomy 21 had a structurally normal heart. The most common cyanotic cardiac lesion was Tetralogy of Fallot, found in twenty-two (9%) children.
|Figure 3: Atrioventricular canal defect (AVCD) in a child with trisomy 21|
Click here to view
[Table 4] shows the pattern and frequencies of acquired heart diseases seen. They accounted for 7.5% of the 240 cases of structural heart defects seen.
Other forms of structural diseases identified in the cohort were dilated cardiomyopathy (2.9%), rheumatic heart disease (2.5%) and pericardial effusion (2.1%). Infective endocarditis was seen as a complication in four patients, three of whom had congenital heart diseases and one with a structurally normal heart.
| Discussion|| |
Structural heart defects (both congenital and acquired) have remained major reasons why children are seen in the Paediatric Cardiology unit.  Echocardiography, a non-invasive diagnostic modality for both cardiac structure and function has further enhanced the diagnosis of structural defects. Its availability in this centre has provided a non-invasive opportunity to reappraise the pattern of structural heart defects five decades after the first review.  It is an essential tool making the diagnosis of structural defects in the developing countries a reality and allows comparisons of frequencies and occurrences of these defects locally and globally.
This study reviewed the pattern of structural defects in our centre after four to five decades of a similar review. , While our review is based on echocardiography, the previous reviews were based on clinical findings, cardiac catheterization and autopsy. Being a non-invasive procedure, echocardiography has become the choice investigation for most congenital heart diseases which decades ago required invasive investigations such as cardiac catheterisation.
This study showed 80% (one hundred and ninety-three) children to be aged five years and below. This finding is consistent with the finding of Jaiyesimi and Antia  five decades ago. The Wilcoxon signed rank test reinforced our finding with children presenting late to the hospital several weeks to months after the onset of symptoms. This finding is consistent with the findings of Jaiyesimi and Antia1 where patients were also diagnosed late. The probable reasons for late presentation would include the lack of proper anomaly scan in pregnancy, deliveries outside the hospital and health care seeking in non-orthodox centres. Late presentation is a well-documented challenge to child healthcare in developing countries. [15-18] Worthy of note is the lack of prenatal diagnosis of congenital heart disease in any of the cases of congenital heart disease.
Our study observed a male preponderance in the patients presenting with structural heart defects. This is consistent with the findings of Jaiyesimi and Antia  where there was male preponderance in all lesions except atrial septal defect and patent ductus arteriosus. Ventricular septal defect had no sexual predilection. Sani et al.  also documented similar findings with a male preponderance in congenital heart diseases.
We found VSD to be the most common congenital heart defect in this study. This is consistent with the findings of Jaiyesimi and Antia,  Sadoh et al.  and Chinawa et al.  This finding is similar to findings in other geographical areas, as described by Kennedy and Miller  in Malawi, Wu  in Taiwan and Reller et al.  in Atlanta. Rahim et al.  however, in Iran found ASD to be the commonest congenital cardiac lesion. Variations in race and gender with regards to the prevalence of specific lesions have been documented by Nembhard et al.  Jaiyesimi and Antia  had also observed the rarity of aortic stenosis and coarctation among the children they studied. Our study found only one case each of aortic stenosis and coarctation of the aorta among the children studied. This shows that the observed pattern has not changed. Jaiyesimi and Antia  had postulated that hypocalcaemia had a protective effect in the children raised in this region because the calcium content of breast milk is less than that in cow milk that is fed to most children in developed countries. No reasons have been found for the variations that exist in the prevalence of specific types of congenital heart diseases. This study showed a higher percentage of Tetralogy of Fallot than found by Jaiyesimi and Antia.  It was the second commonest cardiac lesion in this study. The availability of echocardiography and its ability to detect even mild stenosis and thereby identify ''pink Tetralogy of Fallot'' may have contributed to the higher percentage obtained. This condition also remains the most common cyanotic congenital heart disease. This finding is consistent with findings from Enugu,  Malawi  and Iran  where it was second to ASD.
While Jaiyesimi and Antia  recorded no case of atrioventricular canal defect (AVCD), we found 3.8% of the children with this lesion - occurring exclusively in children with Trisomy 21. This difference may not be unrelated to the non-availability of echocardiography as a diagnostic tool in this centre five decades ago. Furthermore, clinically, AVCD presents like VSD, although close scrutiny of the ECG, with identification of a superior axis should be a pointer to the possibility of its diagnosis.
This study also viewed lesions that occurred in combination. Previous studies did not highlight the common associations. While VSD occurred mostly as a single lesion, it was also the most common lesion occurring in association with ASD and PDA.
Acquired heart diseases constituted about 8% of the cases seen in this study suggesting a relative reduction in the burden of acquired heart diseases compared to congenital heart diseases. Several reasons may be adduced. The widespread use of antibiotics in children, especially the penicillins may have reduced the incidence of acute rheumatic fever and rheumatic heart disease.  Akinwusi et al.  in Nigeria attributed the observed decline of rheumatic heart disease to be due to the primary health care system that was established in Nigeria, prompt diagnosis and treatment of the conditions. Negi et al.  similarly attributed the decline in India to improved healthcare facilities and socioeconomic status, similar to the current situation in Nigeria.
Of note is the fact that dilated cardiomyopathy was more common than either rheumatic heart disease or pericardial effusion. This is at variance with findings of Bode-Thomas et al.  in Jos, Nigeria and Kennedy and Miller  in Malawi, who reported RHD to be the commonest acquired cardiac lesion in children, howbeit among the older children. Their findings were similar to those documented in Ibadan about 3 decades ago, at which time, cardiomyopathies were fourth after pericarditis, endomyocardial fibrosis and RHD.  Although pericarditis remains close to RHD in the present review, its frequency is lower than the previously documented. No case of endomyocardial fibrosis was found in our study. The apparent disappearance of EMF has similarly been observed in Jos,  Lagos  and Kano.  Vijayaraghavan and Sivasankaran  in India have observed the same trend. Several possible reasons have been postulated for this observation; the most favoured being a general improvement in the nutritional status and socioeconomic status of children. In 2007, Oyelami and Ogunlesi  documented a drastic decline in severe acute forms of malnutrition, especially Kwashiorkor.
The gradually increasing frequency of dilated cardiomyopathy, which may be secondary to viral myocarditis, toxins or genetic inheritance has been noted. This calls for the establishment of adequate laboratory facilities to aid aetiological diagnosis of conditions presenting in the form of cardiomyopathies.
This study corroborates the previous findings in various audits that reveal that congenital heart diseases are a significant group of diseases in our environment. Diagnosis has also improved with the availability of the echocardiogram. There is however limited room for definitive intervention in the management of these lesions in the country.
This review, being of a short duration, necessitates continuing review of the cases seen to further authenticate the new trends being observed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]