Original Article
Static balloon atrial septostomy for the purpose of left heart intervention in postoperative adult CHD
- Takanari Fujii, Hideshi Tomita, Yoshihito Hata, Takeshi Sasaki, Dai Asada, Suguru Tarui, Yoshinori Miyahara, Kozo Ishino, Takashi Soga
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- Published online by Cambridge University Press:
- 11 July 2018, pp. 1116-1121
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Background and purpose
Static balloon atrial septostomy is a widely accepted intervention for children with CHD. Successful surgical palliation is creating increasing numbers of adult CHD patients who need subsequent left heart intervention requiring transseptal access. In these patients, the interatrial septum is usually thick and fibrotic because of a previous open heart surgery or catheter intervention, and conventional transseptal puncture may be unsuccessful. Static balloon atrial septostomy to access the left atrium may facilitate intervention via the interatrial septum in such situations. The purpose of this study was to investigate the usefulness and the safety of static balloon atrial septostomy, and the evolution of an iatrogenic atrial septal defect post procedure in adult CHD.
MethodsWe retrospectively reviewed six procedures in five adults with CHD and collected demographic characteristics, details of the procedures, clinical outcome, and size changes of the iatrogenic atrial septal defect.
ResultsThe mean age at the time of the procedure was 35 years. The intended primary interventions were pulmonary vein isolation, stenting for pulmonary vein obstruction, and catheter ablation for focal atrial tachycardia. All static balloon atrial septostomies were effective, and the left heart interventions were successfully achieved via transseptal sheaths. There were no major complications associated with the static balloon atrial septostomy. There were no adverse clinical outcomes related to iatrogenic atrial septal defect, and the size of the defects regressed over time in all cases.
ConclusionsStatic balloon atrial septostomy can be a safe and useful technique in adult CHD patients needing left heart procedures. The thick interatrial septum found in postoperative patients may reduce the risk of persistent iatrogenic atrial septal defect.
The relationship between Interleukin-27 gene polymorphisms and Kawasaki disease in a population of Chinese children
- Feifei Si, Yao Wu, Xianmin Wang, Fang Gao, Dan Yang, Ruixi Liu, Qijian Yi
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- Published online by Cambridge University Press:
- 05 July 2018, pp. 1123-1128
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Background
Kawasaki disease is the leading cause of acquired heart disease in children from developed countries. The Interleukin-6/ Interleukin-12 cytokine family has many members, including the paradoxical anti- and pro-inflammatory Interleukin-27. Recent studies have demonstrated that Interleukin-27 plays a role in immune diseases. Given this, we sought to evaluate the association between Interleukin-27 genetic polymorphisms and Kawasaki disease in Chinese children.
Methods and resultsInterleukin-27 was genotyped in 100 Kawasaki disease children and 98 healthy children (controls), resulting in the direct sequencing of eight Single-nucleotide Polymorphisms: rs17855750, rs40837, rs26528, rs428253, rs4740, rs4905, rs153109, and rs181206). There were no significant differences in Interleukin-27 genotypes between Kawasaki disease and control groups. Of the eight Single-nucleotide Polymorphisms, there was a significant increase in the risk of Kawasaki disease with coronary arterial lesions in children with the rs17855750 (T>G), rs40837 (A>G), rs4740 (G>A), rs4905 (A>G), rs153109 (T>C), and rs26528 (A>G) Single-nucleotide Polymorphisms. This was particularly true for rs17855750 (T>G), which had a greater frequency in Kawasaki disease children with coronary arterial aneurysm.
ConclusionThese findings may be used as risk factors when assessing a child’s likelihood of developing Kawasaki disease, as well as for the development of future therapeutic treatments for Kawasaki disease.
Collective quality improvement in the paediatric cardiology acute care unit: establishment of the Pediatric Acute Care Cardiology Collaborative (PAC3)
- Alaina K. Kipps, Steven C. Cassidy, Courtney M. Strohacker, Margaret Graupe, Katherine E. Bates, Mary C. McLellan, Ashraf S. Harahsheh, Samuel P. Hanke, Ronn E. Tanel, Susan K. Schachtner, Michael Gaies, Nicolas Madsen
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- Published online by Cambridge University Press:
- 28 June 2018, pp. 1019-1023
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Collaborative quality improvement and learning networks have amended healthcare quality and value across specialities. Motivated by these successes, the Pediatric Acute Care Cardiology Collaborative (PAC3) was founded in late 2014 with an emphasis on improving outcomes of paediatric cardiology patients within cardiac acute care units; acute care encompasses all hospital-based inpatient non-intensive care. PAC3 aims to deliver higher quality and greater value care by facilitating the sharing of ideas and building alignment among its member institutions. These aims are intentionally aligned with the work of other national clinical collaborations, registries, and parent advocacy organisations. The mission and early work of PAC3 is exemplified by the formal partnership with the Pediatric Cardiac Critical Care Consortium (PC4), as well as the creation of a clinical registry, which links with the PC4 registry to track practices and outcomes across the entire inpatient encounter from admission to discharge. Capturing the full inpatient experience allows detection of outcome differences related to variation in care delivered outside the cardiac ICU and development of benchmarks for cardiac acute care. We aspire to improve patient outcomes such as morbidity, hospital length of stay, and re-admission rates, while working to advance patient and family satisfaction. We will use quality improvement methodologies consistent with the Model for Improvement to achieve these aims. Membership currently includes 36 centres across North America, out of which 26 are also members of PC4. In this report, we describe the development of PAC3, including the philosophical, organisational, and infrastructural elements that will enable a paediatric acute care cardiology learning network.
Original Articles
Intravenous immunoglobulins in children with new onset dilated cardiomyopathy
- Josephine F. Heidendael, Suzanne L. Den Boer, Joanne G. Wildenbeest, Michiel Dalinghaus, Bart Straver, Dasja Pajkrt
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- Published online by Cambridge University Press:
- 11 August 2017, pp. 46-54
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Background
Dilated cardiomyopathy is a rare but serious disorder in children. No effective diagnostic or treatment tools are readily available. This study aimed to evaluate the efficacy of intravenous immunoglobulins in children with new onset dilated cardiomyopathy.
Methods and resultsIn this retrospective cohort study, 94 children with new onset dilated cardiomyopathy were followed during a median period of 33 months. All patients with secondary dilated cardiomyopathy – for example, genetic, auto-immune or structural defects – had been excluded. Viral tests were performed in all patients and 18 (19%) children met the criteria for the diagnosis “probable or definite viral myocarditis”. Intravenous immunoglobulins were administered to 21 (22%) patients. Overall transplant-free survival was 75% in 5 years and did not differ between treatment groups. The treatment was associated with a higher recovery rate within 5 years, compared with non-treated children (70 versus 43%, log rank=0.045). After correction for possible confounders the hazard ratio for recovery with intravenous immunoglobulins was not significant (hazard ratio: 2.1; 95% CI: 1.0–4.6; p=0.056). Administration of intravenous immunoglobulins resulted in a greater improvement in the shortening fraction of the left ventricle.
ConclusionIn our population of children with new onset dilated cardiomyopathy, of either viral or idiopathic origin, intravenous immunoglobulins were administered to a minority of the patients and did not influence transplant-free survival, but were associated with better improvement of systolic left ventricular function and with better recovery. Our results support the concept that children with new onset dilated cardiomyopathy might benefit from intravenous immunoglobulins.
Presence of reduced regional left ventricular function even in the absence of left ventricular wall scar tissue in the long term after repair of an anomalous left coronary artery from the pulmonary artery
- Sarah Nordmeyer, Boris Schmitt, Boris Nasseri, Vladimir Alexi-Meskishvili, Titus Kuehne, Felix Berger, Johannes Nordmeyer
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- Published online by Cambridge University Press:
- 01 November 2017, pp. 200-207
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Background
We sought to assess left ventricular regional function in patients with and without left ventricular wall scar tissue in the long term after repair of an anomalous origin of the left coronary artery from the pulmonary artery.
MethodsA total of 20 patients aged 12.8±7.4 years were assessed 10 (0.5–17) years after the repair of an anomalous origin of the left coronary artery from the pulmonary artery; of them, 10 (50%) patients showed left ventricular wall scar tissue on current cardiac MRI. Left ventricular regional function was assessed by two-dimensional speckle-tracking echocardiography in 10 patients with scar tissue and 10 patients without scar tissue and in 10 age-matched controls.
ResultsIn patients with scar tissue, MRI-derived left ventricular ejection fraction was significantly reduced compared with that in patients without scar tissue (51 versus 61%, p<0.05), and echocardiography-derived longitudinal strain was significantly reduced in five of six left ventricular areas compared with that in healthy controls (average relative reduction, 46%; p<0.05). In patients without scar tissue, longitudinal strain was significantly reduced in two of six left ventricular areas (average relative reduction, 23%; p<0.05) and circumferential strain was reduced in one of six left ventricular areas (relative reduction, 56%; p<0.05) compared with that in healthy controls.
ConclusionsRegional left ventricular function is reduced even in patients without left ventricular wall scar tissue late after successful repair of an anomalous origin of the left coronary artery from the pulmonary artery. This highlights the need for meticulous lifelong follow-up in all patients with a repaired anomalous origin of the left coronary artery from the pulmonary artery.
Original Article
No difference found in safety or efficacy of balloon atrial septostomy performed at the bedside versus the catheterisation laboratory
- Fabio Savorgnan, Nicholas B. Zaban, Justin J. Elhoff, Michael M. Ross, John P. Breinholt
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- Published online by Cambridge University Press:
- 28 August 2018, pp. 1421-1425
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Background
Balloon atrial septostomy is performed in infants with dextro-transposition of the great arteries to improve oxygenation before surgery. It is performed in the catheterisation laboratory with fluoroscopy or at the bedside using echocardiography. It is unclear whether procedural safety and efficacy is superior in one location versus the other, although the bedside procedure may improve resource utilisation and present an opportunity for reducing cost. This study compares safety and efficacy of atrial septostomy performed at the patient’s bedside versus the catheterisation laboratory.
MethodsNeonates with dextro-transposition of the great arteries who underwent balloon atrial septostomy from October, 2000 to January, 2014 were included. Medical and procedural records, echocardiograms, and catheterisation data were reviewed. Comparisons between the two procedural locations included patient demographics, pre- and post-procedure oxygen saturations, and outcomes. Complications reviewed included bleeding, arrhythmia, cardiac trauma, stroke, and death. Coronary artery evaluations were recorded. T-tests were used for continuous variables, and Fisher’s exact tests were used for all categorical variables. Wilcoxon rank sum and analysis of covariance modelling were used for time variables and oxygen saturation, respectively.
ResultsA total of 88 infants met the inclusion criteria. Among them, 53 underwent septostomy at the bedside and 35 underwent septostomy in the catheterisation laboratory. No safety or outcome benefit was identified between the two procedural locations.
ConclusionSeptostomy performed at the bedside and in the catheterisation laboratory had similar outcomes and efficacy. Further, bedside septostomy has the advantage of no radiation exposure, and obviating risks with patient transfer from the ICU to the catheterisation laboratory.
Original Articles
Impact of prenatal diagnosis on the management and early outcome of critical duct-dependent cardiac lesions
- Varsha Thakur, Nathalie Dutil, Steven M. Schwartz, Edgar Jaeggi
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- Published online by Cambridge University Press:
- 07 February 2018, pp. 548-553
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Objective
The objective of this study was to compare the preoperative management and outcome of neonates with duct-dependent critical CHD with fetal versus postnatal diagnosis.
MethodsPatients referred with CHD to our centre from January 1, 2009 to December 31, 2010 were enrolled prospectively. Live births with a critical form of CHD, a gestational age ⩾36 weeks and a weight ⩾2 kg at birth, and the intention-to-treat were included in this sub-study. Excluded were neonates with lethal non-cardiac and/or genetic anomalies.
ResultsIn total, 129, 63 fetal and 66 postnatal, cases met the study inclusion criteria. All had received appropriate antenatal care, including a routine fetal anatomy scan. Both cohorts were comparable in weight, gestational age, and APGAR scores at birth. Unlike the postnatal cases, there were no deaths (0/63 versus 5/66; p=0.06) and no cardiac arrests (0/63 versus 9/63; p=0.003) before surgery or catheter intervention in those cases with a prenatal diagnosis of critical CHD. Moreover, newborns with fetal diagnoses were admitted earlier (median 0 (range 0–3) versus 2 (0–25) days; p<0.001) and were less likely to require preoperative ventilation (19/63 versus 31/61, p=0.03) and vasoactive medication (4/63 versus 15/61, p=0.006) than the postnatal cases.
ConclusionsPrenatal diagnosis of critical CHD in this study was associated with significantly shorter time intervals from birth to neonatal admission and the absence of life-threatening or fatal preoperative cardiac events. Increased efforts should be made to improve rates of prenatal diagnosis.
The evaluation of arterial stiffness of essential hypertension and white coat hypertension in children: a case-control study
- Semiha Terlemez Tokgöz, Dilek Yılmaz, Yavuz Tokgöz, Bülent Çelik, Yasin Bulut
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- Published online by Cambridge University Press:
- 10 December 2017, pp. 403-408
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Background
The aim of this study was to determine and compare cardiovascular risks by assessing arterial stiffness in children with essential hypertension and white coat hypertension.
MethodsPaediatric patients followed up with essential hypertension and white coat hypertension diagnoses and with no established end organ damage were involved in the study. Arterial stiffness in children included in the study was evaluated and compared by using the oscillometric device (Mobil-O-Graph) method.
ResultsA total of 62 essential hypertension (34 male, 28 female), 38 white coat hypertension (21 male, 17 female), and 60 healthy controls (33 male, 27 female) were assessed in the present study. Pulse wave velocity of the essential hypertension, white coat hypertension, and control group was, respectively, as follows: 5.3±0.6 (m/s), 5.1±0.4 (m/s), 4.3±0.4 (m/s) (p<0.001); augmentation index outcomes were, respectively, determined as follows: 21.3±6.5, 19.3±6.4, 16.0±0.3 (p<0.001). Pulse wave velocity and augmentation index values of children with essential hypertension and white coat hypertension were found to be higher compared with the control group. This level was identified as correlated with the duration of hypertension in both patient groups (p<0.01).
ConclusionArterial stiffness in children with essential hypertension and white coat hypertension was impaired compared with healthy children. This finding has made us think that white coat hypertension is not an innocent clinical situation. This information should be taken into consideration in the follow-up and treatment approaches of the patients.
Prevalence and risk factors associated with non-attendance in neurodevelopmental follow-up clinic among infants with CHD
- Eméfah C. Loccoh, Sunkyung Yu, Janet Donohue, Ray Lowery, Jennifer Butcher, Sara K. Pasquali, Caren S. Goldberg, Karen Uzark
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- Published online by Cambridge University Press:
- 23 January 2018, pp. 554-560
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Background
Neurodevelopmental impairment is increasingly recognised as a potentially disabling outcome of CHD and formal evaluation is recommended for high-risk patients. However, data are lacking regarding the proportion of eligible children who actually receive neurodevelopmental evaluation, and barriers to follow-up are unclear. We examined the prevalence and risk factors associated with failure to attend neurodevelopmental follow-up clinic after infant cardiac surgery.
MethodsSurvivors of infant (<1 year) cardiac surgery at our institution (4/2011-3/2014) were included. Socio-demographic and clinical characteristics were evaluated in neurodevelopmental clinic attendees and non-attendees in univariate and multivariable analyses.
ResultsA total of 552 patients were included; median age at surgery was 2.4 months, 15% were premature, and 80% had moderate–severe CHD. Only 17% returned for neurodevelopmental evaluation, with a median age of 12.4 months. In univariate analysis, non-attendees were older at surgery, had lower surgical complexity, fewer non-cardiac anomalies, shorter hospital stay, and lived farther from the surgical center. Non-attendee families had lower income, and fewer were college graduates or had private insurance. In multivariable analysis, lack of private insurance remained independently associated with non-attendance (adjusted odds ratio 1.85, p=0.01), with a trend towards significance for distance from surgical center (adjusted odds ratio 2.86, p=0.054 for ⩾200 miles).
ConclusionsThe majority of infants with CHD at high risk for neurodevelopmental dysfunction evaluated in this study are not receiving important neurodevelopmental evaluation. Efforts to remove financial/insurance barriers, increase access to neurodevelopmental clinics, and better delineate other barriers to receipt of neurodevelopmental evaluation are needed.
Additional mechanism for left ventricular dysfunction: chronic pulmonary regurgitation decreases left ventricular preload in patients with tetralogy of Fallot
- Pekka Ylitalo, Eero Jokinen, Kirsi Lauerma, Miia Holmström, Olli M. Pitkänen-Argillander
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- Published online by Cambridge University Press:
- 11 October 2017, pp. 208-213
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Background
Right ventricular dysfunction in patients with tetralogy of Fallot and significant pulmonary regurgitation may lead to systolic dysfunction of the left ventricle due to altered ventricular interaction. We were interested in determining whether chronic pulmonary regurgitation affects the preload of the left ventricle. In addition, we wanted to study whether severe chronic pulmonary regurgitation would alter the preload of the left ventricle when compared with patients having preserved pulmonary valve annulus.
MethodsThe study group comprised 38 patients with tetralogy of Fallot who underwent surgical repair between 1990 and 2003. Transannular patching was required in 21 patients to reconstruct the right ventricular outflow tract. Altogether, 48 age- and gender-matched healthy volunteers were recruited. Cardiac MRI was performed on all study patients to assess the atrial and ventricular volumes and function.
ResultsSevere pulmonary regurgitation (>30 ml/m2) was present in 13 patients, of whom 11 had a transannular patch, but only two had a preserved pulmonary valve annulus. The ventricular preload volumes from both atria were significantly reduced in patients with severe pulmonary regurgitation, and left ventricular stroke volumes (44.1±4.7 versus 58.9±10.7 ml/m2; p<0.0001) were smaller compared with that in patients with pulmonary regurgitation <30 ml/m2 or in controls.
ConclusionsIn patients with tetralogy of Fallot, severe pulmonary regurgitation has a significant effect on volume flow through the left atrium. Reduction in left ventricular preload volume may be an additional factor contributing to left ventricular dysfunction.
Original Article
Mid-term follow-up study of neonatal isolated aberrant right subclavian artery
- Sheng-Ling Jan, Ming-Chih Lin, Sheng-Ching Chan
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- Published online by Cambridge University Press:
- 28 June 2018, pp. 1024-1030
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Background
Aberrant right subclavian artery is the most common congenital aortic arch anomaly. There are a few reports concerning the clinical manifestations and follow-up of this CHD detected by echocardiographic screening.
MethodsA total of 1737 full-term neonates, with a male-to-female ratio of 900:837, received echocardiographic screening. Neonates with or without isolated aberrant right subclavian artery were studied during infancy.
ResultsAmong the 1737 cases, a total of 15 (0.86%) female-predominant neonates, with a male-to-female ratio of 6:9, had isolated aberrant right subclavian artery. They were compared with 20 age- and gender-matched normal neonates. There were no significant differences in maternal age, gestational age, or para gravity between the two groups, except for birth size (birth length- and weight-for-age percentiles, p = 0.006 and 0.045, respectively), which was smaller in the aberrant right subclavian artery group. Although there were no significant differences in developmental history, gastrointestinal, or respiratory symptoms, neonates with aberrant right subclavian artery had a higher incidence of mild developmental delay and feeding difficulty than normal infants (21 versus 0%, p = 0.061; 36 versus 20%, p = 0.264, respectively). The growth rates of body length and weight during infancy were not significantly different between the two groups.
ConclusionsEchocardiography can be applied as a first-line investigation in the diagnostic work-up for aberrant right subclavian artery. Neonates with aberrant right subclavian artery had a smaller size at birth, although growth rates were not significantly different from those of normal infants. This study does not support an active surgical policy for asymptomatic infants with isolated aberrant right subclavian artery. A larger study and longer follow-up of affected infants is recommended.
Review of children with Takayasu’s arteritis at a Southern African tertiary care centre
- Antoinette M. Cilliers, Paul E. Adams, Hopewell Ntsinjana, Udai Kala
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- Published online by Cambridge University Press:
- 06 July 2018, pp. 1129-1135
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Introduction
Takayasu’s arteritis is a rare idiopathic arteritis causing stenosis or aneurysms of the aorta, pulmonary arteries, and their branches. It usually occurs in women, but has been described in children.
ObjectiveThe objective of this study was to determine the clinical presentation, demographic profile, vascular involvement, origins, management, and outcome of children diagnosed with Takayasu’s arteritis at a Southern African tertiary care centre between 1993 and 2015.
MethodsThis is a retrospective analysis of all children with Takayasu’s arteritis captured on a computerised electronic database during the study period.
ResultsA total of 55 children were identified. The female:male ratio was 3.2:1, and the mean age was 9.7±3.04 years. Most originated outside the provincial borders of the study centre. The majority presented with hypertension and heart failure. In all, 37 (67%) patients had a cardiomyopathy with a mean fractional shortening of 15±5%. A positive purified protein derivative test was documented in 73%. Abdominal aorta and renal artery stenosis were the predominant angiographic lesions. A total of 23 patients underwent 30 percutaneous interventions of the aorta, pulmonary, and renal arteries: eight stents, 22 balloon angioplasties, and seven had nephrectomies. All patients received empiric tuberculosis treatment, immunosuppressive therapy, and anti-hypertensive agents as required. Overall, there was a significant reduction in systolic blood pressure and improvement in fractional shortening (p<0.05) with all treatments.
ConclusionTakayasu’s arteritis is more common in girls and frequently manifests with hypertension and heart failure. The abdominal aorta and renal arteries are mostly affected. Immunosuppressive, anti-hypertensive, and vascular intervention therapies improve blood pressure control and cardiac function.
Postoperative feeding problems in patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals undergoing unifocalisation surgery
- Andrew M. Koth, Charlotte Sakarovitch, Douglas R. Sidell, Lisa M. Schultz, Allison Freccero, Sandra Rizzuto, Frank L. Hanley, Ritu Asija
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- Published online by Cambridge University Press:
- 02 August 2018, pp. 1329-1332
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Background
Patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals are at risk for prolonged hospitalisation after unifocalisation. Feeding problems after congenital heart surgery are associated with longer hospital stay. We sought to determine the impact of baseline, intra-operative, and postoperative factors on the need for feeding tube use at the time of discharge.
MethodsWe included patients with the aforementioned diagnosis undergoing unifocalisation from ages 3 months to 4 years from 2010 to 2016. We excluded patients with a pre-existing feeding tube. Patients discharged with an enteric tube were included in the feeding tube group. We compared the feeding tube group with the non-feeding-tube group by univariable and multi-variable logistic regression.
ResultsOf the 56 patients studied, 41% used tube feeding. Median age and weight z-score were similar in the two groups. A chromosome 22q11 deletion was associated with the need for a feeding tube (22q11 deletion in 39% versus 15%, p=0.05). Median cardiopulmonary bypass time in the feeding tube group was longer (335 versus 244 minutes, p=0.04). Prolonged duration of mechanical ventilation was associated with feeding tube use (48 versus 3%, p=0.001). On multi-variable analysis, prolonged mechanical ventilation was associated with feeding tube use (odds ratio 10.2, 95% confidence intervals 1.6; 63.8).
ConclusionAmong patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals who were feeding by mouth before surgery, prolonged mechanical ventilation after unifocalisation surgery was associated with feeding tube use at discharge. Anticipation of feeding problems in this population and earlier feeding tube placement may reduce hospital length of stay.
Original Articles
Cardiac function in children with premature ventricular contractions: the effect of omega-3 polyunsaturated fatty acid supplementation
- Taliha Oner, Rahmi Ozdemir, Onder Doksöz, Dildar B. Genc, Baris Guven, Savas Demirpence, Murat M. Yilmazer, Yilmaz Yozgat, Timur Mese, Vedide Tavli
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- Published online by Cambridge University Press:
- 15 May 2018, pp. 949-954
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Background
Premature ventricular contractions are accepted as benign in structurally normal hearts. However, reversible cardiomyopathy can sometimes develop. Omega-3 polyunsaturated fatty acids have anti-arrhythmic properties in animals and humans.
AimWe evaluated left ventricular function in children with premature ventricular contractions with normal cardiac anatomy and assessed the impact of omega-3 fatty acid supplementation on left ventricular function in a prospective trial.
MethodsA total of 25 patients with premature ventricular contraction, with more than 2% premature ventricular contractions on 24-hour Holter electrocardiography, and 30 healthy patients were included into study. All patients underwent electrocardiography, left ventricular M-mode echocardiography, and myocardial performance index testing. Patients with premature ventricular contraction were given omega-3 fatty acids at a dose of 1 g/day for 3 months, and control echocardiography and 24-hour Holter electrocardiography were performed. Neither placebo nor omega-3 fatty acids were given to the control group.
ResultsCompared with the values of the control group, the patients with premature ventricular contraction had significantly lower fractional shortening. The myocardial performance index decreased markedly in the patient groups. The mean heart rate and mean premature ventricular contraction percentage of Group 2 significantly decreased in comparison with their baseline values after the omega-3 supplementation.
ConclusionIn conclusion, premature ventricular contractions can lead to systolic cardiac dysfunction in children. Omega-3 supplementation may improve cardiac function in children with premature ventricular contractions. This is the first study conducted in children to investigate the possible role of omega-3 fatty acid supplementation on treatment of premature ventricular contractions.
Diagnostic errors in paediatric cardiac intensive care
- Priya N. Bhat, John M. Costello, Ranjit Aiyagari, Paul J. Sharek, Claudia A. Algaze, Mjaye L. Mazwi, Stephen J. Roth, Andrew Y. Shin
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- Published online by Cambridge University Press:
- 07 February 2018, pp. 675-682
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Introduction
Diagnostic errors cause significant patient harm and increase costs. Data characterising such errors in the paediatric cardiac intensive care population are limited. We sought to understand the perceived frequency and types of diagnostic errors in the paediatric cardiac ICU.
MethodsPaediatric cardiac ICU practitioners including attending and trainee physicians, nurse practitioners, physician assistants, and registered nurses at three North American tertiary cardiac centres were surveyed between October 2014 and January 2015.
ResultsThe response rate was 46% (N=200). Most respondents (81%) perceived that diagnostic errors harm patients more than five times per year. More than half (65%) reported that errors permanently harm patients, and up to 18% perceived that diagnostic errors contributed to death or severe permanent harm more than five times per year. Medication side effects and psychiatric conditions were thought to be most commonly misdiagnosed. Physician groups also ranked pulmonary overcirculation and viral illness to be commonly misdiagnosed as bacterial illness. Inadequate care coordination, data assessment, and high clinician workload were cited as contributory factors. Delayed diagnostic studies and interventions related to the severity of the patient’s condition were thought to be the most commonly reported process breakdowns. All surveyed groups ranked improving teamwork and feedback pathways as strategies to explore for preventing future diagnostic errors.
ConclusionsPaediatric cardiac intensive care practitioners perceive that diagnostic errors causing permanent harm are common and associated more with systematic and process breakdowns than with cognitive limitations.
Original Article
Efficacy of catheter interventions in the early and very early postoperative period after CHD operation
- Takuro Kojima, Tomohiko Imamura, Yousuke Osada, Shouta Muraji, Marie Nakano, Takayuki Oyanagi, Shigeki Yoshiba, Toshiki Kobayashi, Naokata Sumitomo
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- Published online by Cambridge University Press:
- 03 September 2018, pp. 1426-1430
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Background
Catheter interventions for residual lesions in the early postoperative period after CHD operations are still not established as a reliable treatment option.
MethodsWe retrospectively reviewed our institutional experience of cardiac catheterisations and catheter interventions performed in the early postoperative period. We classified our patients into two groups. The “hyper” acute phase group – operation to cardiac catheterisation of ⩽7 days – and acute phase group – operation to cardiac catheterisation from 7 to 30 days.
ResultsOf the 47 patients, catheter interventions were performed in 38 patients (81%). The success rate of the intervention was 96% in the acute phase group and 90% in the “hyper” acute phase group. The overall success rate was 95%. There were two self-limited complications in the acute phase group, but not in the “hyper” acute phase group. There were four cases of catheter interventions performed for a newly reconstructed aortic arch, and those procedures were also safe and effective.
ConclusionsCardiac catheterisations and catheter interventions were safe and effective not only in the early postoperative period but also in the very early postoperative period. Catheter interventions for the left-sided heart in the early postoperative period were also safe and effective.
Original Articles
Symptomatic myocardial bridging: a frequently occurring coronary variation can cause severe myocardial ischaemia in affected children with underlying cardiac conditions
- Alexandra Kiess, Marcel Vollroth, Farhad Bakhtiary, Hiroshi Seki, Martin Kostelka, Milan Djukic, Ingo Daehnert, Robert Wagner
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- Published online by Cambridge University Press:
- 16 May 2018, pp. 826-831
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Myocardial bridging is a congenital coronary artery anomaly in which the coronary artery has a partly “tunnelled” intramyocardial course. This tunnelling leads to compression of the affected vessel segment during ventricular systole. It is considered to be a benign variation of the norm in about 25% of the population caused by an aberrancy of embryologic coronary development. The bridging is also thought to cause severe cardiac conditions in a few of those affected. The series of six young patients presented here is the largest series so far to report on symptomatic myocardial bridging in children with different underlying heart diseases. All patients recently presented to our centre with signs of myocardial ischaemia. They subsequently underwent coronary angiography, which revealed myocardial bridging of the ramus interventricularis anterior. In all patients, therapy with β blockers was started to reduce heart rate and myocardial contractility. β Blocker treatment was also given in order to prolong diastole and improve coronary artery blood flow. Two patients underwent surgical exposure of the involved coronary segment: a 2-year-old boy because of recurrent, severe myocardial ischaemia in combination with a reduction of general health, changes in ST-segments, and the presence of a dilative cardiomyopathy; and a 13-year-old girl because of evidence of myocardial ischaemia during exercise testing after surviving sudden cardiac death. Surgery was successful and recovery was complete and uneventful. The presented series shows that myocardial bridging can be symptomatic and may require urgent treatment and even surgical intervention in early childhood in rare cases.
Impaired cerebral autoregulation and elevation in plasma glial fibrillary acidic protein level during cardiopulmonary bypass surgery for CHD
- Ronald B. Easley, Bradley S. Marino, Jacky Jennings, Amy E. Cassedy, Kathleen K. Kibler, Ken M. Brady, Dean B. Andropoulos, Marissa Brunetti, Charles W. Hogue, Eugenie S. Heitmiller, Jennifer K. Lee, James Spaeth, Allen D. Everett
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- Published online by Cambridge University Press:
- 24 August 2017, pp. 55-65
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Background
Cerebrovascular reactivity monitoring has been used to identify the lower limit of pressure autoregulation in adult patients with brain injury. We hypothesise that impaired cerebrovascular reactivity and time spent below the lower limit of autoregulation during cardiopulmonary bypass will result in hypoperfusion injuries to the brain detectable by elevation in serum glial fibrillary acidic protein level.
MethodsWe designed a multicentre observational pilot study combining concurrent cerebrovascular reactivity and biomarker monitoring during cardiopulmonary bypass. All children undergoing bypass for CHD were eligible. Autoregulation was monitored with the haemoglobin volume index, a moving correlation coefficient between the mean arterial blood pressure and the near-infrared spectroscopy-based trend of cerebral blood volume. Both haemoglobin volume index and glial fibrillary acidic protein data were analysed by phases of bypass. Each patient’s autoregulation curve was analysed to identify the lower limit of autoregulation and optimal arterial blood pressure.
ResultsA total of 57 children had autoregulation and biomarker data for all phases of bypass. The mean baseline haemoglobin volume index was 0.084. Haemoglobin volume index increased with lowering of pressure with 82% demonstrating a lower limit of autoregulation (41±9 mmHg), whereas 100% demonstrated optimal blood pressure (48±11 mmHg). There was a significant association between an individual’s peak autoregulation and biomarker values (p=0.01).
ConclusionsIndividual, dynamic non-invasive cerebrovascular reactivity monitoring demonstrated transient periods of impairment related to possible silent brain injury. The association between an impaired autoregulation burden and elevation in the serum brain biomarker may identify brain perfusion risk that could result in injury.
Original Article
Impact of modified techniques of transcatheter closure in large atrial septal defects (⩾30 mm) with anatomic complexities
- Ajith Ananthakrishna Pillai, Amarnath Upadhyay, Saranya Gousy, Amit Handa
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- Published online by Cambridge University Press:
- 23 July 2018, pp. 1122-1133
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Objective
The outcome of transcatheter closure in ostium secundum atrial septal defects is determined by the morphology of the defects. Modified techniques such as balloon assistance, pulmonary vein deployment, left atrial roof technique, and so on are used for circumventing the anatomic complexities and increasing the success rates.
MethodsWe planned a prospective study looking at the outcomes of transcatheter closure in secundum atrial septal defects with modified techniques in different anatomic complexities identified in transoesophageal echocardiography and their association with outcome of transcatheter closure.
ResultsTranscatheter closure was successful in 295 out of 346 (82%) patients with modified techniques. Balloon-assisted technique offered a success rate of 87%. The mean defect size was 34.7±2.78 mm (95% confidence interval (CI) 30.67–43.1 mm) with success and 40.16±4.5 mm (95% CI 32.16–44.7) with failure (p = 0.02). The mean total septal length was 38.11±0.63 (95% CI 35.21–40.56 mm) with success and 42.54±0.34 (95% CI 38.79–43.21 mm) with failure. The defect to septal ratios were 0.82 and 0.94 in success and failure groups, respectively (p=0.02). However, the absence of a retro-aortic margin, septal aneurysm, and multiple defects did not affect the success rate. Deficient inferior vena caval margin, deficient posterior margin, and size⩾40 mm had a high risk of failure with transcatheter closure. The odds ratio for procedural failure was 25.3 (4.3–143.8) in patients with malaligned septum, 8.3(1.4–48.5) with deficient inferior vena caval margin, and 4.1(2.5–19) for size⩾40 mm.
ConclusionsThe modified techniques for device deployment offer substantial chances of success in transcatheter closure of secundum atrial septal defects with anatomical complexity (82%). Variants such as defect size of⩾40 mm and deficient inferior and posterior margins have high failure rates with a modified technique.
Original Articles
Efficacy and safety of recombinant tissue plasminogen activator for venous thrombosis after paediatric heart surgery
- Lindsey B. Justice, David P. Nelson, Joseph Palumbo, Jaclyn Sawyer, Manish N. Patel, Jonathan W. Byrnes
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- Published online by Cambridge University Press:
- 11 September 2017, pp. 214-221
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Objective
Reports in the literature of treatment with recombinant tissue plasminogen activator following cardiac surgery are limited. We reviewed our experience to provide a case series of the therapeutic use of tissue plasminogen activator for the treatment of venous thrombosis in children after cardiac surgery. The data describe the morbidity, mortality, and clinical outcomes of tissue plasminogen activator administration for treatment of venous thrombosis in children following cardiac surgery.
DesignThe study was designed as a retrospective case series.
SettingThe study was carried out in a 25-bed cardiac intensive care unit in an academic, free-standing paediatric hospital.
PatientsAll children who received tissue plasminogen activator for venous thrombosis within 60 days of cardiac surgery, a total of 13 patients, were included.
InterventionsData was collected, collated, and analysed as a part of the interventions of this study.
Measurements and main resultsPatients treated with tissue plasminogen activator were principally young infants (median 0.2, IQR 0.07–0.58 years) who had recently (22, IQR 12.5–27.3 days) undergone cardiac surgery. Hospital mortality was high in this patient group (38%), but there was no mortality attributable to tissue plasminogen activator administration, occurring within <72 hours. There was one major haemorrhagic complication that may be attributable to tissue plasminogen activator. Complete or partial resolution of venous thrombosis was confirmed using imaging in 10 of 13 patients (77%), and tissue plasminogen activator administration was associated with resolution of chylous drainage, with no drainage through chest tubes, at 10 days after tissue plasminogen activator treatment in seven of nine patients who had upper-compartment venous thrombosis-associated chylothorax.
ConclusionsOn the basis of our experience with administration of tissue plasminogen activator in children after cardiac surgery, tissue plasminogen activator is both safe and effective for resolution of venous thrombosis in this high-risk population.