A case of a neonatal cardiac tumor with ventricular tachycardia undergoing emergency surgery

A case of a neonatal cardiac tumor with ventricular tachycardia undergoing emergency surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A case of a neonatal cardiac tumor with ventricular tachycardia undergoing emergency surgery Pengju Li, Bo Zhai, Yihua Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5413124/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Feb, 2025 Read the published version in BMC Pediatrics → Version 1 posted 10 You are reading this latest preprint version Abstract Background Primary heart tumors are more common in children, often without obvious symptoms. However, a small number of children may experience serious conditions such as arrhythmia, heart obstruction, and even death. When severe arrhythmia cannot be controlled by conservative treatment, surgical intervention is needed. Case presentation: A 20-day-old male neonate, born full-term via cesarean section, was admitted to the emergency department with complaints of jaundice for 16 days and a rapid heart rate detected for one day. The heart rate was recorded at 280 beats per minute. An electrocardiogram (ECG) initially suggested supraventricular tachycardia, later progressing to ventricular tachycardia. A bedside echocardiogram indicated an intracardiac mass. Conservative treatment failed to restore normal heart rhythm, then the patient underwent emergency surgery with tumor resection under general anesthesia and cardiopulmonary bypass. Post-surgery, ventilator-assisted breathing was administered, along with inotropic support, diuretics, anti-infective therapy, and fluid management. the heart rate and rhythm returned to normal. Postoperative pathology revealed the presence of a cardiac rhabdomyoma, and follow-up was arranged post-discharge. Conclusion Cardiac tumors in children are relatively rare, mostly benign, and have a good prognosis. But for some emergency situations or heart tumors that cause adverse effects, timely and effective intervention is needed to avoid adverse consequences. Neonatal Cardiac Tumor Ventricular Tachycardia Emergency Surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Cardiac tumors are neoplasms that originate from the pericardium, myocardium, or endocardium and can occur across all age groups. They are classified as either primary or secondary. In children, primary tumors are most common, and approximately 80% of them are benign, leading to a relatively favorable prognosis. While many pediatric cardiac tumors remain asymptomatic, some patients may present with arrhythmias, syncope, or heart failure, which can pose significant risks. In this case, the neonate initially presented with arrhythmias due to a cardiac tumor. Pharmacological and electrical cardioversion were unsuccessful in controlling the arrhythmias, prompting an emergency surgical intervention, which resulted in a favorable outcome. Case Presentation 1. General Information The patient is a 20-day-old male, G1P1, born full-term via cesarean section, with no history of resuscitation at birth. The child was admitted to the emergency department due to jaundice for 16 days and a fast heart rate detected for one day. Upon admission, the heart rate was recorded at 280 beats per minute. An ECG initially indicated supraventricular tachycardia, which later progressed to ventricular tachycardia. Bedside echocardiography revealed an intracardiac mass. Specialized Examination: The patient was alert but had poor responses, with blackish-yellow skin and mucous membranes. There was pigment deposition on the areolae and scrotum, scattered red rashes, round purplish bruises on the chest, and dry, peeling skin without petechiae. The sclera were jaundiced, the fontanel was flat and soft, and the neck was supple. The lips were rosy, breathing was rapid, but there were no retraction signs. Coarse breath sounds were heard in both lungs, without dry or wet rales. The heart rate was 280 beats per minute, with strong heart sounds and a regular rhythm. No obvious pathological murmurs were heard in the precordium. The abdomen was distended but soft, with the liver palpable 4 cm below the right costal margin and a soft texture. The spleen was not palpable, bowel sounds were normal, and the extremities were cool, with a capillary refill time of 3 seconds. The limbs had normal muscle tone, but primitive reflexes were incompletely elicited. 2. Examination (1) Laboratory Tests: Blood gas analysis, urinalysis, coagulation tests, renal function tests, hepatitis B panel, and infection markers showed no abnormalities. Total bilirubin was elevated to 367.5 μmol/L, with unconjugated bilirubin at 363.0 μmol/L. Hemoglobin was 144 g/L. Pro-B-type natriuretic peptide (proBNP) was over 35,000 pg/mL. Troponin T was 0.215 ng/mL. (2) Imaging: (1) Chest and abdominal X-rays revealed coarse and increased lung markings, with no significant abnormalities in the abdomen. (2) ECG indicated supraventricular tachycardia upon admission, which gradually evolved into ventricular tachycardia (Figure 1). (3) Echocardiography showed slight enlargement of both the left and right atria. A highly echogenic mass measuring approximately 14.9 mm × 4.8 mm was observed adjacent to the posterior leaflet of the mitral valve, partly located on the left ventricular side and partly on the left atrial side, altering the flow direction through the mitral valve. The foramen ovale was patent, and moderate regurgitation was noted at both the mitral and tricuspid valves, with a false tendon in the left ventricle (Figure 3). (3) Diagnosis: Neonatal rhabdomyoma, neonatal hyperbilirubinemia, neonatal arrhythmia (supraventricular tachycardia, ventricular tachycardia). (4) Treatment: The patient was admitted to the neonatal intensive care unit for continuous ECG monitoring and phototherapy. Initial ECG revealed supraventricular tachycardia, which improved with antiarrhythmic medication. However, on the following day, ventricular tachycardia developed. After a consultation with the cardiology department, antiarrhythmic drugs and synchronized cardioversion were ineffective. Bedside echocardiography indicated an intracardiac mass, suggesting that the arrhythmia was caused by the obstruction from the mass. Since pharmacological or electrical interventions could not resolve the obstruction or completely correct the arrhythmia, emergency surgery was deemed necessary. After consultation, the anesthesiology, cardiopulmonary bypass, blood transfusion, and surgical intensive care departments were informed, and emergency surgery was performed. Intraoperative Findings (Figure 4): Under general anesthesia and mild hypothermic cardiopulmonary bypass, tumor resection was performed along with mitral and tricuspid valve repair and closure of the patent foramen ovale. The patient was placed in a supine position, and a median sternotomy was made. The pericardium was incised and suspended. Exploration revealed cardiomegaly, primarily involving the left atrium and ventricle, with an atrioventricular ratio of 0.8:1.0. A solid, yellowish mass measuring 1.5 cm × 0.8 cm × 0.8 cm was found near the posterior mitral annulus. Another similar mass, 0.5 cm × 0.5 cm × 0.5 cm, was located on the left ventricular side below the mitral valve. The mitral valve annulus was dilated, leading to severe regurgitation, while the tricuspid annulus was moderately dilated with moderate regurgitation. The foramen ovale was patent, measuring 0.2 cm × 0.2 cm. The coronary arteries appeared normal. Standard cardiopulmonary bypass was initiated, and cold crystalloid cardioplegia was administered for myocardial protection. A right atriotomy and exploration of the septum were performed, revealing the previously described masses. Both masses were meticulously excised, and the mitral annulus was plicated using a 6/0 Prolene suture. The water test confirmed the disappearance of regurgitation. Tricuspid valve repair was performed using a figure-eight stitch on the posterior leaflet annulus. The patent foramen ovale was closed, and air was evacuated from the left heart. The heart spontaneously resumed sinus rhythm. The right atriotomy was closed with a continuous 6/0 Prolene suture, and the patient was successfully weaned from cardiopulmonary bypass. Protamine was used to neutralize heparin, and meticulous hemostasis was achieved. The pericardium was partially closed with interrupted sutures, and one mediastinal drainage tube was placed. The lungs were inflated, instruments and sponges were counted, and the chest was closed in a delayed fashion. The surgery was uneventful, with approximately 30 mL of intraoperative blood loss, 50 mL of autotransfused blood, and 60 mL of crystalloid infusion. Urine output was 50 mL. Myocardial ischemia time was 55 minutes, and cardiopulmonary bypass time was 90 minutes. The patient was transferred back to the surgical intensive care unit for monitoring, with special attention to vital signs and drain management. (5) Treatment Outcome, Follow-up, and Prognosis: On the day after surgery, the ECG showed a sinus rhythm (Figure 2), and the postoperative echocardiogram revealed no significant abnormalities. At the 3-month follow-up, the patient exhibited normal mental and physical development, with appropriate weight gain and good appetite and sleep. Discussion Cardiac tumors can be classified into two types: primary tumors that originate within cardiac tissue and secondary tumors that spread from other tissues to the heart. Primary cardiac tumors are rare in all age groups, while secondary tumors are 30 times more common than primary ones [ 1 ]. Most primary cardiac tumors are benign, with myxomas being the most common in adults, while nearly half of pediatric cardiac tumors are rhabdomyomas. Other common pediatric cardiac tumors include fibromas, intrapericardial teratomas, myxomas, and hemangiomas [ 2 ]. The incidence of primary cardiac tumors in children ranges from 0.027–0.080%. Although rare, their presence, whether benign or malignant, can lead to serious consequences due to the heart's critical function in the body. The symptoms of cardiac tumors depend on their size, location, invasiveness, number, and growth rate. Patients may be asymptomatic or present with symptoms such as outflow tract obstruction, congestive heart failure, arrhythmias, pericardial effusion, syncope, or sudden death. Arrhythmias associated with cardiac tumors can manifest as cardiac arrest, ventricular fibrillation, ventricular tachycardia, or supraventricular tachycardia[ 3 , 4 ]. In this case, the neonate experienced frequent arrhythmias that initially presented as supraventricular tachycardia but later evolved into ventricular tachycardia. The arrhythmias were not controlled with medication, and the patient's blood pressure fluctuated, necessitating emergency surgery to save the child's life. Diagnosing cardiac tumors is not difficult. Chest X-rays and ECGs may show abnormalities, though these findings are often nonspecific. Echocardiography is the most accessible non-invasive diagnostic technique and is often used to detect cardiac masses incidentally. Echocardiography can accurately and rapidly assess the tumor's location, size, and characteristics, making it the preferred diagnostic tool. Cardiac magnetic resonance imaging (MRI), with its ability to offer multiple imaging planes and superior tissue characterization, provides a more precise assessment of cardiac tumors, delineating the relationship between the tumor, normal myocardium, and major vessels. MRI can also help differentiate between cardiac tumors and thrombi, offering supplementary information to echocardiography [ 5 ]. Angiography was once considered a primary diagnostic tool for cardiac tumors; however, modern catheterization techniques are now reserved for select cases where congenital heart disease or hemodynamic assessment is necessary, particularly when coronary artery involvement is suspected. For tumors in the right heart system, endomyocardial biopsy via catheterization may be performed preoperatively to guide therapeutic strategies. However, most cases require intraoperative or postoperative pathological examination. In 1954, Crafoord [ 6 ] performed the first successful resection of an atrial myxoma using cardiopulmonary bypass. In pediatric patients, most cardiac tumors are benign, and if they do not cause significant clinical symptoms or hemodynamic compromise, surgery may not be necessary. This is particularly true for rhabdomyomas, which may regress spontaneously over time [ 4 , 7 ]. Multicenter studies in Europe suggest that the timing of surgery for pediatric cardiac tumors should be based on the patient's clinical symptoms and the degree of ECG or echocardiographic abnormalities[ 8 ]. When surgery is indicated, complete excision of the tumor is necessary to prevent local invasion and recurrence [ 3 ]. However, when complete resection would compromise vital cardiac structures, partial resection is often performed. Whether complete or partial, surgical treatment of cardiac tumors is a viable option, with postoperative echocardiographic follow-up required to monitor for potential complications such as ventricular aneurysms or cardiac dysfunction [ 9 ]. In this case, the neonate presented with sustained ventricular tachycardia that affected hemodynamics and posed a life-threatening risk. The cardiac tumor was large and located near the mitral annulus, occupying both the left atrium and left ventricle, obstructing blood flow and causing mitral and tricuspid regurgitation. During surgery, careful dissection was required to differentiate the tumor from the mitral valve tissue and excise it without damaging surrounding structures such as the valve annulus, chordae tendineae, or leaflets. When plicating the annulus, care was taken to avoid suturing into the coronary and pulmonary veins. Although the patient resumed sinus rhythm postoperatively, given the neonate’s young age and the myocardial edema following surgery, there was a risk of low cardiac output syndrome or persistent arrhythmias. Therefore, delayed chest closure was performed, and the patient was managed with supportive care until the chest was successfully closed three days later. The pathological nature of the excised cardiac tumor determines the patient’s treatment strategy and prognosis. Rhabdomyomas are benign tumors of cardiac myocytes and are more common in neonates and infants, with the potential for spontaneous regression. Asymptomatic patients can be followed with echocardiography, and surgery is generally not required [ 4 ]. Symptomatic patients may present with heart murmurs, obstructive symptoms, or arrhythmias. Surgery is indicated for patients with arrhythmias refractory to medical management or those with hemodynamic obstruction. In this case, the patient had a rhabdomyoma located near the mitral valve annulus, presenting with malignant arrhythmias—ventricular tachycardia unresponsive to medication. After tumor excision, the patient returned to sinus rhythm, and no further arrhythmias were observed during follow-up. Additionally, rhabdomyomas are often associated with tuberous sclerosis, an autosomal dominant genetic disorder. Tuberous sclerosis can affect any organ system, with the classic triad including cortical tubers causing seizures, intellectual disability, and characteristic skin lesions (adenoma sebaceum). Thus, it is essential to monitor patients with cardiac rhabdomyomas for the subsequent development of these clinical features. There have been reports of using mTOR inhibitors (such as sirolimus and everolimus) to treat fetal rhabdomyomas associated with tuberous sclerosis in pregnant women. However, due to the limited number of cases, the optimal dosage, efficacy, and safety of these drugs require further investigation [ 10 ]. Cardiac tumors in children are relatively rare, mostly benign, and have a good prognosis. But for some emergency situations or heart tumors that cause adverse effects, timely and effective intervention is needed to avoid adverse consequences. Cardiac surgery during the neonatal period is difficult and requires comprehensive diagnosis and treatment during the perioperative period. Abbreviations ECG: electrocardiogram LA: left atrium LV: left ventricle Declarations Acknowledgements Not applicable. Author’s contributions PJL drafted the initial manuscript, ZB and YHC revised the manuscript.All authors read and approved the final manuscript. Funding None. Data availability No datasets were generated or analysed during the current study. Clinical trial number Not applicable. Ethics approval and consent to participate This study involving the collection and analysis of patient case data was conducted in accordance with ethical principles, and all procedures were carried out following the Declaration of Helsinki. The study strictly adhered to patient confdentiality and privacy standards. Informed consent was obtained from the parents (also the legal guardians) of the child patient, and all the data were anonymized to ensure the protection of personal information. Ethics approval was not needed for this case report. Consent for publication Informed consent was obtained from the parents/legal guardians of all the participants included in the study. Competing interests The authors declare no competing interests. References Goldberg AD, Blankstein R, Padera RF. Tumors metastatic to the heart[J]. Circulation, 2013, 128(16): 1790-1794. DOI:10.1161/CIRCULATIONAHA.112.000790. Poterucha TJ, Kochav J, O’Connor DS, et al. Cardiac tumors: clinical presentation, diagnosis, and management[J]. Curr Treat Options Oncol. 2019;20(8):66. DOI: 10.1007/s11864-019-0662-1. Jin Y, Li XM, Liu R, et al. Surgical treatment of primary cardiac tumor associated with malignant arrhythmias[J]. Heart Surg Forum, 2020, 23(2): E178-E182. DOI: 10.1532/hsf.2823. Kwiatkowska J, Wałdoch A, Meyer-Szary J, et al. Cardiac tumors in children: a 20-year review of clinical presentation, diagnostics and treatment[J]. Adv Clin Exp Med, 2017, 26(2): 319-326. DOI: 10.17219/acem/62121. Hoey ET, Shahid M, Ganeshan A, Baijal S, et al. MRI assessment of cardiac tumours: part 1, multiparametric imaging protocols and spectrum of appearances of histologically benign lesions[J]. Quant Imaging Med Surg, 2014, 4(6): 478-488. doi: 10.3978/j.issn.2223-4292.2014.11.23. Chitwood WR Jr. Clarence Crafoord and the first successful resection of a cardiac myxoma[J]. Ann Thorac Surg, 1992, 54(5): 997-998. DOI: 10.1016/0003-4975(92)90676-u. Shi L, Wu L, Fang H, et al. Identification and clinical course of 166 pediatric cardiac tumors[J]. Eur J Pediatr, 2017, 176(2): 253-260. DOI: 10.1007/s00431-016-2833-4. Padalino MA, Vida VL, Boccuzzo G, et al. Surgery for primary cardiac tumors in children: early and late results in a multicenter European Congenital Heart Surgeons Association study[J]. Circulation, 2012, 126(1): 22-30. DOI: 10.1161/CIRCULATIONAHA.111.037226. Miyake CY, Del Nido PJ, Alexander ME, et al. Cardiac tumors and associated arrhythmias in pediatric patients, with observations on surgical therapy for ventricular tachycardia[J]. J Am Coll Cardiol, 2011, 58(18): 1903-1909. DOI: 10.1016/j.jacc.2011.08.005. Ebrahimi-Fakhari D, Stires G, Hahn E, et al. Prenatal sirolimus treatment for rhabdomyomas in tuberous sclerosis[J]. Pediatr Neurol, 2021, 125: 26-31. DOI: 10.1016/j.pediatrneurol.2021.09.014. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 Feb, 2025 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 02 Dec, 2024 Reviews received at journal 29 Nov, 2024 Reviewers agreed at journal 29 Nov, 2024 Reviews received at journal 29 Nov, 2024 Reviewers agreed at journal 27 Nov, 2024 Reviewers invited by journal 25 Nov, 2024 Editor invited by journal 25 Nov, 2024 Editor assigned by journal 20 Nov, 2024 Submission checks completed at journal 20 Nov, 2024 First submitted to journal 07 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5413124","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":385153052,"identity":"0543461a-6389-4993-87e1-74e03d26cf98","order_by":0,"name":"Pengju Li","email":"","orcid":"","institution":"Children’s Hospital Affiliated of Zhengzhou University, Henan Children’s Hospital Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Pengju","middleName":"","lastName":"Li","suffix":""},{"id":385153053,"identity":"176bd453-41c5-4b4e-9098-4e8f7024573f","order_by":1,"name":"Bo Zhai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYDACCQaGwwwMNTxszMwHDnz4QbyWY3L87G2JB2f2EKmFGYiMJXvOGB/mYCNCh/zs5oeHCyrYEjfcyPlwmIGHQZ5f7AB+LYxzjhkcnnFGBqgld8PhAgsGw5mzE/BrYZZIMDjM28YG0TKDhyHB4DYBLWwS6R+AWphBDntwmIeNCC08EjkgW8DeZyBOi4RETgHQL+BANgAGsgRhv8jPSN/8uaACHJWPP3z4YSPPL01AC4atpCkfBaNgFIyCUYAdAAA/HEgQU0/RMAAAAABJRU5ErkJggg==","orcid":"","institution":"Children’s Hospital Affiliated of Zhengzhou University, Henan Children’s Hospital Zhengzhou University","correspondingAuthor":true,"prefix":"","firstName":"Bo","middleName":"","lastName":"Zhai","suffix":""},{"id":385153054,"identity":"6d438d3a-f86f-40d0-b9df-494c1e779095","order_by":2,"name":"Yihua Chen","email":"","orcid":"","institution":"Children’s Hospital Affiliated of Zhengzhou University, Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Yihua","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-11-08 02:53:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5413124/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5413124/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-025-05514-x","type":"published","date":"2025-02-28T15:57:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71925742,"identity":"9eeb68ab-ca96-45d9-bd51-a12cf8ee85fb","added_by":"auto","created_at":"2024-12-19 18:42:46","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":323804,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative ECG: ventricular tachycardia\u003c/p\u003e","description":"","filename":"1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5413124/v1/250e15da5cfe57e17fda7ed6.jpeg"},{"id":71925744,"identity":"ec0b5dfb-1ffd-47fd-bd44-0d4f543faa1e","added_by":"auto","created_at":"2024-12-19 18:42:46","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":276055,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative ECG: sinus rhythm\u003c/p\u003e","description":"","filename":"2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5413124/v1/187462fe1ac17c3828f7feff.jpeg"},{"id":71925745,"identity":"3e749d54-aeb4-414b-b843-29490bf2137e","added_by":"auto","created_at":"2024-12-19 18:42:46","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":74420,"visible":true,"origin":"","legend":"\u003cp\u003eTwo dimensional images of preoperative cardiac ultrasound. LA: left atrium, LV: left ventricle（What is measured is the cardiac tumor）\u003c/p\u003e","description":"","filename":"3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5413124/v1/04d69de6801aff9ec04fb68a.jpeg"},{"id":71926044,"identity":"2fc2d2e7-3991-46e8-86bd-7b5f7127d048","added_by":"auto","created_at":"2024-12-19 18:50:46","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":218221,"visible":true,"origin":"","legend":"\u003cp\u003ethe appearance after right atrial incision during surgery (The thing pointed by the arrow is the cardiac tumor)\u003c/p\u003e","description":"","filename":"4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5413124/v1/88c059a6de861485c92756d4.jpeg"},{"id":77622347,"identity":"f68580ff-75bf-4932-96f8-3330e246cf66","added_by":"auto","created_at":"2025-03-03 16:04:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1270532,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5413124/v1/faa4aaca-258c-4eb0-a1e4-b41dbdb72cbb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A case of a neonatal cardiac tumor with ventricular tachycardia undergoing emergency surgery","fulltext":[{"header":"Background","content":"\u003cp\u003eCardiac tumors are neoplasms that originate from the pericardium, myocardium, or endocardium and can occur across all age groups. They are classified as either primary or secondary. In children, primary tumors are most common, and approximately 80% of them are benign, leading to a relatively favorable prognosis. While many pediatric cardiac tumors remain asymptomatic, some patients may present with arrhythmias, syncope, or heart failure, which can pose significant risks. In this case, the neonate initially presented with arrhythmias due to a cardiac tumor. Pharmacological and electrical cardioversion were unsuccessful in controlling the arrhythmias, prompting an emergency surgical intervention, which resulted in a favorable outcome.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003e1. General Information\u003c/p\u003e\n\u003cp\u003eThe patient is a 20-day-old male, G1P1, born full-term via cesarean section, with no history of resuscitation at birth. The child was admitted to the emergency department due to jaundice for 16 days and a fast heart rate detected for one day. Upon admission, the heart rate was recorded at 280 beats per minute. An ECG initially indicated supraventricular tachycardia, which later progressed to ventricular tachycardia. Bedside echocardiography revealed an intracardiac mass. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSpecialized Examination: The patient was alert but had poor responses, with blackish-yellow skin and mucous membranes. There was pigment deposition on the areolae and scrotum, scattered red rashes, round purplish bruises on the chest, and dry, peeling skin without petechiae. The sclera were jaundiced, the fontanel was flat and soft, and the neck was supple. The lips were rosy, breathing was rapid, but there were no retraction signs. Coarse breath sounds were heard in both lungs, without dry or wet rales. The heart rate was 280 beats per minute, with strong heart sounds and a regular rhythm. No obvious pathological murmurs were heard in the precordium. The abdomen was distended but soft, with the liver palpable 4 cm below the right costal margin and a soft texture. The spleen was not palpable, bowel sounds were normal, and the extremities were cool, with a capillary refill time of 3 seconds. The limbs had normal muscle tone, but primitive reflexes were incompletely elicited. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. Examination \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(1) Laboratory Tests: Blood gas analysis, urinalysis, coagulation tests, renal function tests, hepatitis B panel, and infection markers showed no abnormalities. Total bilirubin was elevated to 367.5 \u0026mu;mol/L, with unconjugated bilirubin at 363.0 \u0026mu;mol/L. Hemoglobin was 144 g/L. Pro-B-type natriuretic peptide (proBNP) was over 35,000 pg/mL. Troponin T was 0.215 ng/mL. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(2) Imaging: (1) Chest and abdominal X-rays revealed coarse and increased lung markings, with no significant abnormalities in the abdomen. (2) ECG indicated supraventricular tachycardia upon admission, which gradually evolved into ventricular tachycardia (Figure 1). (3) Echocardiography showed slight enlargement of both the left and right atria. A highly echogenic mass measuring approximately 14.9 mm \u0026times; 4.8 mm was observed adjacent to the posterior leaflet of the mitral valve, partly located on the left ventricular side and partly on the left atrial side, altering the flow direction through the mitral valve. The foramen ovale was patent, and moderate regurgitation was noted at both the mitral and tricuspid valves, with a false tendon in the left ventricle (Figure 3). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(3) Diagnosis: Neonatal rhabdomyoma, neonatal hyperbilirubinemia, neonatal arrhythmia (supraventricular tachycardia, ventricular tachycardia). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(4) Treatment: The patient was admitted to the neonatal intensive care unit for continuous ECG monitoring and phototherapy. Initial ECG revealed supraventricular tachycardia, which improved with antiarrhythmic medication. However, on the following day, ventricular tachycardia developed. After a consultation with the cardiology department, antiarrhythmic drugs and synchronized cardioversion were ineffective. Bedside echocardiography indicated an intracardiac mass, suggesting that the arrhythmia was caused by the obstruction from the mass. Since pharmacological or electrical interventions could not resolve the obstruction or completely correct the arrhythmia, emergency surgery was deemed necessary. After consultation, the anesthesiology, cardiopulmonary bypass, blood transfusion, and surgical intensive care departments were informed, and emergency surgery was performed. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIntraoperative Findings (Figure 4): Under general anesthesia and mild hypothermic cardiopulmonary bypass, tumor resection was performed along with mitral and tricuspid valve repair and closure of the patent foramen ovale. The patient was placed in a supine position, and a median sternotomy was made. The pericardium was incised and suspended. Exploration revealed cardiomegaly, primarily involving the left atrium and ventricle, with an atrioventricular ratio of 0.8:1.0. A solid, yellowish mass measuring 1.5 cm \u0026times; 0.8 cm\u0026nbsp;\u0026times;\u0026nbsp;0.8 cm was found near the posterior mitral annulus. Another similar mass, 0.5 cm \u0026times; 0.5 cm \u0026times; 0.5 cm, was located on the left ventricular side below the mitral valve. The mitral valve annulus was dilated, leading to severe regurgitation, while the tricuspid annulus was moderately dilated with moderate regurgitation. The foramen ovale was patent, measuring 0.2 cm \u0026times; 0.2 cm. The coronary arteries appeared normal. Standard cardiopulmonary bypass was initiated, and cold crystalloid cardioplegia was administered for myocardial protection. A right atriotomy and exploration of the septum were performed, revealing the previously described masses. Both masses were meticulously excised, and the mitral annulus was plicated using a 6/0 Prolene suture. The water test confirmed the disappearance of regurgitation. Tricuspid valve repair was performed using a figure-eight stitch on the posterior leaflet annulus. The patent foramen ovale was closed, and air was evacuated from the left heart. The heart spontaneously resumed sinus rhythm. The right atriotomy was closed with a continuous 6/0 Prolene suture, and the patient was successfully weaned from cardiopulmonary bypass. Protamine was used to neutralize heparin, and meticulous hemostasis was achieved. The pericardium was partially closed with interrupted sutures, and one mediastinal drainage tube was placed. The lungs were inflated, instruments and sponges were counted, and the chest was closed in a delayed fashion. The surgery was uneventful, with approximately 30 mL of intraoperative blood loss, 50 mL of autotransfused blood, and 60 mL of crystalloid infusion. Urine output was 50 mL. Myocardial ischemia time was 55 minutes, and cardiopulmonary bypass time was 90 minutes. The patient was transferred back to the surgical intensive care unit for monitoring, with special attention to vital signs and drain management. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(5) Treatment Outcome, Follow-up, and Prognosis: \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the day after surgery, the ECG showed a sinus rhythm (Figure 2), and the postoperative echocardiogram revealed no significant abnormalities. At the 3-month follow-up, the patient exhibited normal mental and physical development, with appropriate weight gain and good appetite and sleep. \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCardiac tumors can be classified into two types: primary tumors that originate within cardiac tissue and secondary tumors that spread from other tissues to the heart. Primary cardiac tumors are rare in all age groups, while secondary tumors are 30 times more common than primary ones [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Most primary cardiac tumors are benign, with myxomas being the most common in adults, while nearly half of pediatric cardiac tumors are rhabdomyomas. Other common pediatric cardiac tumors include fibromas, intrapericardial teratomas, myxomas, and hemangiomas [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe incidence of primary cardiac tumors in children ranges from 0.027\u0026ndash;0.080%. Although rare, their presence, whether benign or malignant, can lead to serious consequences due to the heart's critical function in the body. The symptoms of cardiac tumors depend on their size, location, invasiveness, number, and growth rate. Patients may be asymptomatic or present with symptoms such as outflow tract obstruction, congestive heart failure, arrhythmias, pericardial effusion, syncope, or sudden death. Arrhythmias associated with cardiac tumors can manifest as cardiac arrest, ventricular fibrillation, ventricular tachycardia, or supraventricular tachycardia[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In this case, the neonate experienced frequent arrhythmias that initially presented as supraventricular tachycardia but later evolved into ventricular tachycardia. The arrhythmias were not controlled with medication, and the patient's blood pressure fluctuated, necessitating emergency surgery to save the child's life.\u003c/p\u003e \u003cp\u003eDiagnosing cardiac tumors is not difficult. Chest X-rays and ECGs may show abnormalities, though these findings are often nonspecific. Echocardiography is the most accessible non-invasive diagnostic technique and is often used to detect cardiac masses incidentally. Echocardiography can accurately and rapidly assess the tumor's location, size, and characteristics, making it the preferred diagnostic tool. Cardiac magnetic resonance imaging (MRI), with its ability to offer multiple imaging planes and superior tissue characterization, provides a more precise assessment of cardiac tumors, delineating the relationship between the tumor, normal myocardium, and major vessels. MRI can also help differentiate between cardiac tumors and thrombi, offering supplementary information to echocardiography [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Angiography was once considered a primary diagnostic tool for cardiac tumors; however, modern catheterization techniques are now reserved for select cases where congenital heart disease or hemodynamic assessment is necessary, particularly when coronary artery involvement is suspected. For tumors in the right heart system, endomyocardial biopsy via catheterization may be performed preoperatively to guide therapeutic strategies. However, most cases require intraoperative or postoperative pathological examination.\u003c/p\u003e \u003cp\u003eIn 1954, Crafoord [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] performed the first successful resection of an atrial myxoma using cardiopulmonary bypass. In pediatric patients, most cardiac tumors are benign, and if they do not cause significant clinical symptoms or hemodynamic compromise, surgery may not be necessary. This is particularly true for rhabdomyomas, which may regress spontaneously over time [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Multicenter studies in Europe suggest that the timing of surgery for pediatric cardiac tumors should be based on the patient's clinical symptoms and the degree of ECG or echocardiographic abnormalities[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. When surgery is indicated, complete excision of the tumor is necessary to prevent local invasion and recurrence [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, when complete resection would compromise vital cardiac structures, partial resection is often performed. Whether complete or partial, surgical treatment of cardiac tumors is a viable option, with postoperative echocardiographic follow-up required to monitor for potential complications such as ventricular aneurysms or cardiac dysfunction [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In this case, the neonate presented with sustained ventricular tachycardia that affected hemodynamics and posed a life-threatening risk. The cardiac tumor was large and located near the mitral annulus, occupying both the left atrium and left ventricle, obstructing blood flow and causing mitral and tricuspid regurgitation. During surgery, careful dissection was required to differentiate the tumor from the mitral valve tissue and excise it without damaging surrounding structures such as the valve annulus, chordae tendineae, or leaflets. When plicating the annulus, care was taken to avoid suturing into the coronary and pulmonary veins. Although the patient resumed sinus rhythm postoperatively, given the neonate\u0026rsquo;s young age and the myocardial edema following surgery, there was a risk of low cardiac output syndrome or persistent arrhythmias. Therefore, delayed chest closure was performed, and the patient was managed with supportive care until the chest was successfully closed three days later.\u003c/p\u003e \u003cp\u003eThe pathological nature of the excised cardiac tumor determines the patient\u0026rsquo;s treatment strategy and prognosis. Rhabdomyomas are benign tumors of cardiac myocytes and are more common in neonates and infants, with the potential for spontaneous regression. Asymptomatic patients can be followed with echocardiography, and surgery is generally not required [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Symptomatic patients may present with heart murmurs, obstructive symptoms, or arrhythmias. Surgery is indicated for patients with arrhythmias refractory to medical management or those with hemodynamic obstruction. In this case, the patient had a rhabdomyoma located near the mitral valve annulus, presenting with malignant arrhythmias\u0026mdash;ventricular tachycardia unresponsive to medication. After tumor excision, the patient returned to sinus rhythm, and no further arrhythmias were observed during follow-up. Additionally, rhabdomyomas are often associated with tuberous sclerosis, an autosomal dominant genetic disorder. Tuberous sclerosis can affect any organ system, with the classic triad including cortical tubers causing seizures, intellectual disability, and characteristic skin lesions (adenoma sebaceum). Thus, it is essential to monitor patients with cardiac rhabdomyomas for the subsequent development of these clinical features. There have been reports of using mTOR inhibitors (such as sirolimus and everolimus) to treat fetal rhabdomyomas associated with tuberous sclerosis in pregnant women. However, due to the limited number of cases, the optimal dosage, efficacy, and safety of these drugs require further investigation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCardiac tumors in children are relatively rare, mostly benign, and have a good prognosis. But for some emergency situations or heart tumors that cause adverse effects, timely and effective intervention is needed to avoid adverse consequences. Cardiac surgery during the neonatal period is difficult and requires comprehensive diagnosis and treatment during the perioperative period.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eECG: electrocardiogram\u003c/p\u003e\n\u003cp\u003eLA: left atrium\u003c/p\u003e\n\u003cp\u003eLV: left ventricle\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePJL drafted the initial manuscript, ZB and YHC revised the manuscript.All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNone.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study involving the collection and analysis of patient case data was conducted in accordance with ethical principles, and all procedures were carried out following the Declaration of Helsinki. The study strictly adhered to patient confdentiality and privacy standards. Informed consent was obtained from the parents (also the legal guardians) of the child patient, and all the data were anonymized to ensure the protection of personal information. Ethics approval was not needed for this case report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the parents/legal guardians of all the participants included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGoldberg AD, Blankstein R, Padera RF. Tumors metastatic to the heart[J]. Circulation, 2013, 128(16): 1790-1794. DOI:10.1161/CIRCULATIONAHA.112.000790.\u003c/li\u003e\n\u003cli\u003ePoterucha TJ, Kochav J, O\u0026rsquo;Connor DS, et al. Cardiac tumors: clinical presentation, diagnosis, and management[J]. Curr Treat Options Oncol. 2019;20(8):66. DOI: 10.1007/s11864-019-0662-1.\u003c/li\u003e\n\u003cli\u003eJin Y, Li XM, Liu R, et al. Surgical treatment of primary cardiac tumor associated with malignant arrhythmias[J]. Heart Surg Forum, 2020, 23(2): E178-E182. DOI: 10.1532/hsf.2823.\u003c/li\u003e\n\u003cli\u003eKwiatkowska J, Wałdoch A, Meyer-Szary J, et al. Cardiac tumors in children: a 20-year review of clinical presentation, diagnostics and treatment[J]. Adv Clin Exp Med, 2017, 26(2): 319-326. DOI: 10.17219/acem/62121.\u003c/li\u003e\n\u003cli\u003eHoey ET, Shahid M, Ganeshan A, Baijal S, et al. MRI assessment of cardiac tumours: part 1, multiparametric imaging protocols and spectrum of appearances of histologically benign lesions[J]. Quant Imaging Med Surg, 2014, 4(6): 478-488. doi: 10.3978/j.issn.2223-4292.2014.11.23.\u003c/li\u003e\n\u003cli\u003eChitwood WR Jr. Clarence Crafoord and the first successful resection of a cardiac myxoma[J]. Ann Thorac Surg, 1992, 54(5): 997-998. DOI: 10.1016/0003-4975(92)90676-u.\u003c/li\u003e\n\u003cli\u003eShi L, Wu L, Fang H, et al. Identification and clinical course of 166 pediatric cardiac tumors[J]. Eur J Pediatr, 2017, 176(2): 253-260. DOI: 10.1007/s00431-016-2833-4.\u003c/li\u003e\n\u003cli\u003ePadalino MA, Vida VL, Boccuzzo G, et al. Surgery for primary cardiac tumors in children: early and late results in a multicenter European Congenital Heart Surgeons Association study[J]. Circulation, 2012, 126(1): 22-30. DOI: 10.1161/CIRCULATIONAHA.111.037226.\u003c/li\u003e\n\u003cli\u003eMiyake CY, Del Nido PJ, Alexander ME, et al. Cardiac tumors and associated arrhythmias in pediatric patients, with observations on surgical therapy for ventricular tachycardia[J]. J Am Coll Cardiol, 2011, 58(18): 1903-1909. DOI: 10.1016/j.jacc.2011.08.005.\u003c/li\u003e\n\u003cli\u003eEbrahimi-Fakhari D, Stires G, Hahn E, et al. Prenatal sirolimus treatment for rhabdomyomas in tuberous sclerosis[J]. Pediatr Neurol, 2021, 125: 26-31. DOI: 10.1016/j.pediatrneurol.2021.09.014.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Neonatal Cardiac Tumor, Ventricular Tachycardia, Emergency Surgery","lastPublishedDoi":"10.21203/rs.3.rs-5413124/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5413124/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePrimary heart tumors are more common in children, often without obvious symptoms. However, a small number of children may experience serious conditions such as arrhythmia, heart obstruction, and even death. When severe arrhythmia cannot be controlled by conservative treatment, surgical intervention is needed.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 20-day-old male neonate, born full-term via cesarean section, was admitted to the emergency department with complaints of jaundice for 16 days and a rapid heart rate detected for one day. The heart rate was recorded at 280 beats per minute. An electrocardiogram (ECG) initially suggested supraventricular tachycardia, later progressing to ventricular tachycardia. A bedside echocardiogram indicated an intracardiac mass. Conservative treatment failed to restore normal heart rhythm, then the patient underwent emergency surgery with tumor resection under general anesthesia and cardiopulmonary bypass. Post-surgery, ventilator-assisted breathing was administered, along with inotropic support, diuretics, anti-infective therapy, and fluid management. the heart rate and rhythm returned to normal. Postoperative pathology revealed the presence of a cardiac rhabdomyoma, and follow-up was arranged post-discharge.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCardiac tumors in children are relatively rare, mostly benign, and have a good prognosis. But for some emergency situations or heart tumors that cause adverse effects, timely and effective intervention is needed to avoid adverse consequences.\u003c/p\u003e","manuscriptTitle":"A case of a neonatal cardiac tumor with ventricular tachycardia undergoing emergency surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-19 18:42:41","doi":"10.21203/rs.3.rs-5413124/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-02T12:27:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-29T17:22:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56978196342507406879830215462272211102","date":"2024-11-29T16:30:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-29T08:24:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225232814772895826902600126138294290018","date":"2024-11-27T10:26:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-25T07:48:42+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-11-25T07:29:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-20T14:33:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-20T14:33:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2024-11-08T02:46:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fcbc6bbc-f73f-4487-9762-631b6d7471a0","owner":[],"postedDate":"December 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-03T15:59:19+00:00","versionOfRecord":{"articleIdentity":"rs-5413124","link":"https://doi.org/10.1186/s12887-025-05514-x","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2025-02-28 15:57:03","publishedOnDateReadable":"February 28th, 2025"},"versionCreatedAt":"2024-12-19 18:42:41","video":"","vorDoi":"10.1186/s12887-025-05514-x","vorDoiUrl":"https://doi.org/10.1186/s12887-025-05514-x","workflowStages":[]},"version":"v1","identity":"rs-5413124","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5413124","identity":"rs-5413124","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}