Review
How best can we name the channels seen in the setting of deficient ventricular septation?
- Robert H. Anderson, Diane E. Spicer, Colin J. McMahon, R. Krishna Kumar, Justin T. Tretter
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- Published online by Cambridge University Press:
- 01 December 2023, pp. 1-10
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Surgical repair of channels between the ventricles is enhanced when the surgeon knows precisely where to place a patch, or baffle, so as to restore septal integrity. The paediatric cardiologist should provide the necessary information. Communication will be enhanced if the same words are used to account for the structures in question. Currently, however, the same term, namely “ventricular septal defect,” is used to account for markedly different areas within the heart. Closure of perimembranous defects found in hearts with concordant or discordant ventriculo-arterial connections restores the integrity of the ventricular septum, at the same time separating the systemic and pulmonary blood streams. When both arterial trunks arise from the right ventricle, in contrast, the surgeon when placing a baffle so as to separate the blood streams, does not close the channel most frequently described as the “ventricular septal defect.” In this review, we show that the perimembranous lesions as found in hearts with concordant or discordant ventriculo-arterial connections are the right ventricular entrances to the areas subtended beneath the hinges of the leaflets of the aortic or pulmonary valves. When both arterial trunks arise from the right ventricle, and the channel between the ventricles is directly subaortic, then the channel termed the “ventricular septal defect” is the left ventricular entrance to the comparable space subtended beneath the aortic root. We argue that recognition of these fundamental anatomical differences enhances the appreciation of the underlying morphology of the various lesions that reflect transfer, during cardiac development, of the aortic root from the morphologically right to the morphologically left ventricle.
Original Article
Comparison of echocardiographic aortic stiffness index measurements and pulse wave velocity measurements in obese and overweight children
- Akif Kavgacı, Fatma İncedere, Sedef Tunaoğlu, Muhammet Karabörk, Bahar Büyükkaragöz, Emre Leventoğlu, Deniz Oğuz, Serdar Kula, Semiha Terlemez
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- Published online by Cambridge University Press:
- 21 June 2023, pp. 11-17
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Background:
Aortic/arterial stiffness is a reliable, independent predictor and a risk factor for cardiovascular mortality. Arterial stiffness is assessed by pulse wave velocity and echocardiography. The purpose of this study is to analyse aortic/arterial stiffness in patients using echocardiographic and pulse wave velocity techniques.
Materials and Methods:The participants of this study consisted of 62 patients who presented to the Gazi University Pediatric Endocrinology and Pediatric Cardiology outpatient clinics, including 21 obese, 20 overweight, and 21 normal-weight patients. Echocardiography was performed on all patients, and echocardiographic measurements were compared to pulse wave velocity measurements.
Results:The mean (min-max) arterial strain measurements were 0.146 ± 0.0 (0.06–0.3) in the obese group and 0.106 ± 0.0 (0.05–0.18) in the overweight group. In comparison to the overweight group, the obese group had greater arterial strain measurements. The pulse wave velocity measurements in the obese and overweight groups were greater than those in the normal weight group (p > 0.05). Elastic modulus and aortic stiffness ß index values were shown to be positively correlated with pulse wave velocity measurements in the obese group (r = 0.56, r = 0.53, respectively; p = 0.008, p = 0.01, respectively). Systolic and diastolic blood pressure measurements were correlated with pulse wave velocity measurements in the obese group (r = 0.98, p = 0.0001, respectively).
Conclusion:In our study, echocardiographic aortic measurements showing the vessel wall were correlated with pulse wave velocity measurements. Echocardiographic evaluation should be included in the routine follow-up of patients because pulse wave velocity measurement devices are not available in all centres, echocardiography is available in many centres, it is easily applicable, and it facilitates the follow-up of patients.
Self-reported quality of life before, during, and after pregnancy in women with CHD
- Frida Wedlund, Joanna Hlebowicz
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- 03 May 2023, pp. 18-23
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Background:
Adults with CHD are a growing patient group and childbirth is a relatively new phenomenon. EQ-5D is commonly used to measure health-related quality of life. We sought to investigate EQ-5D status before, during, and after pregnancy in women with CHD.
Methods:We identified 128 pregnancies in 86 CHD women giving birth in Skåne County during 2009–2021. Repeated measures ANOVA was performed to test for differences between the five EQ-5D domains, EQ-VAS, and EQ-index over time points before, the second trimester, the third trimester, and after pregnancy.
Results:Mean age at estimated childbirth was 30.3 (± 4.7) years; 56.25% of births were vaginal deliveries and 43.75% were Caesarean sections. The cohort consisted of patients with double outlet right ventricle (4.7%), transposition (Mustard/Senning 2.3%, arterial switch 4.7%), aortic anomalies (19.5%), Fallot’s anomaly (16.4%), single ventricle (3.9%), shunt lesions (11.7%), cardiomyopathies (4.7%), coronary anomalies (1.6%), arrythmias (0.8%), and valve lesions: aortic (19.5%), mitral (5.5%), and pulmonary (4.7%). The women reported significantly worse mobility (p = 0.007) and higher pain/discomfort (p = 0.049) at trimester 3 compared to before pregnancy. The women had lower EQ-5D index during trimester 3 compared to after pregnancy (p = 0.004). We saw worse mobility during Tri 2 comparing multiparity with primiparity (p = 0.046). Looking at delivery mode, we noted significantly higher anxiety/depression before pregnancy (p =0.023) in women that had a Caesarean section.
Conclusions:In this study, women with CHD reported worse mobility and a higher pain level during Tri 3, although the overall health-related quality of life is acceptably high.
Percutaneous approach to residual pulmonary bifurcation stenosis in conotruncal diseases
- Biagio Castaldi, Angela Di Candia, Elena Cuppini, Domenico Sirico, Elena Reffo, Massimo Padalino, Vladimiro Vida, Giovanni Di Salvo
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- 04 May 2023, pp. 24-31
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Residual stenosis after right ventricle outflow tract surgery represents a major issue to manage in the children and adult patient with conotruncal defects. Despite a detailed multimodality imaging, the anatomy of distal pulmonary trunk and pulmonary artery bifurcation may be challenging in these patients.
The aim of this study was to analyse retrospectively the outcome of the percutaneous transcatheter treatment in children with post-surgical stenosis of pulmonary artery bifurcation.
We enrolled 39 patients with a median age of 6.0 years. Standard high-pressure balloon dilation was attempted in 33 patients, effective in 5 of them. Pulmonary branch stenting was performed in 10 patients, effective in 6. A kissing balloon approach was chosen in 17 patients (6 after angioplasty or stenting failure), and this technique was effective in 16 cases. Finally, a bifurcation stenting was performed in 10 patients (second step in 9 cases), effective in all the cases. None of the patients approached by kissing balloon needed a bifurcation stenting.
In conclusion, standard balloon angioplasty and standard stenting might be ineffective in post-surgical stenosis involving pulmonary artery bifurcation. In this population, kissing balloon or bifurcation stenting, followed by side branch de-jailing, may be more effective in relieving the gradient.
The effect of long-term use of methylphenidate on cardiac autonomic functions and ventricular arrhythmogenesis: a prospective case–control study
- Rahmi Ozdemir, Yaşar Tanır, Batuhan Berk Demir, Seheryeli Yılmaz, Damla Geçkalan Soysal, Cem Karadeniz
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- 04 May 2023, pp. 32-36
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Objective:
We aimed to assess cardiac autonomic balance with heart rate variability by using 24-hour Holter electrocardiography and also to assess susceptibility to ventricular arrhythmias by using microvolt T wave alternance in children with attention deficit hyperactivity disorder.
Method:This study was conducted with age- and gender-matched groups of 40 patients taking long-acting methylphenidate for more than a year and 55 healthy controls. Heart rate variability analysis for cardiac autonomic functions and microvolt T wave alternance measurements for susceptibility to ventricular arrhythmias were evaluated by 24-hour Holter electrocardiography.
Results:The mean age 10.9 ± 2.7 years, mean duration of therapy 22.76 months, and mean methylphenidate doses were 37.64 mg/day. The study group had considerably higher rMSSD, higher HF, and a lower LF/HF ratio (respectively, p : 0.02, p : 0.001 and p : 0.01). While parasympathetic activity parameters were elevated, sympathetic activity parameters were low during the sleep period. Increase in the microvolt T wave alternance values of the study group was not found to be statistically significant (p > 0.05).
Conclusion:In children taking long-acting methylphenidate, the autonomic balance was shown to be in favour of the parasympathetic system. Determination of the vulnerability to life-threatening ventricular arrhythmias has been evaluated for the first time in children with attention deficit hyperactivity disorder. Accordingly, microvolt T-wave alternance values give the notion that drug use is safe.
Navigating the healthcare system with my child with CHD: parental perspectives on developmental follow-up practices
- Marie-Eve Bolduc, Janet E. Rennick, Isabelle Gagnon, Eva Sokol, Annette Majnemer, Marie Brossard-Racine
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- 04 May 2023, pp. 37-43
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Background:
Parents of children with CHD face several barriers when trying to access the services needed to support their child’s development. In fact, current developmental follow-up practices may not identify developmental challenges in a timely manner and important opportunities for interventions may be lost. This study aimed to explore the perspectives of parents of children and adolescents with CHD with respect to developmental follow-up in Canada.
Methods:Interpretive description was used as a methodological approach for this qualitative study. Parents of children aged 5–15 years with complex CHD were eligible. Semi-structured interviews that aimed to explore their perspectives regarding their child’s developmental follow-up were conducted.
Results:Fifteen parents of children with CHD were recruited for this study. They expressed that the lack of systematic and responsive developmental follow-up services and limited access to resources to support their child’s development placed an undue burden on their families, and as a result, they needed to assume new roles as case managers or advocates to address these limitations. This additional burden resulted in a high level of parental stress, which, in turn, affected the parent–child relationship and siblings.
Conclusions:The limitations of the current Canadian developmental follow-up practices put undue pressure on the parents of children with complex CHD. The parents stressed the importance of implementing a universal and systematic approach to developmental follow-up to allow for the timely identification of challenges, enabling the initiation of interventions and supports and promoting more positive parent–child relationships.
Initiative to increase family presence and participation in daily rounds on a paediatric acute care cardiology unit
- Dana B. Gal, Colleen M. Pater, Mackenzie McGinty, Greta Lobes, Christy Tuemler, Paula M. Eldridge, Brittany Frakes, Elisa Marcuccio, Samuel P. Hanke, Michael G. Gaies
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- 04 May 2023, pp. 44-49
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Introduction:
Family-centred rounds benefit families and clinicians and improve outcomes in general paediatrics, but are understudied in subspecialty settings. We sought to improve family presence and participation in rounds in a paediatric acute care cardiology unit.
Methods:We created operational definitions for family presence, our process measure, and participation, our outcome measure, and gathered baseline data over 4 months of 2021. Our SMART aim was to increase mean family presence from 43 to 75% and mean family participation from 81 to 90% by 30 May, 2022. We tested interventions with iterative plan-do-study-act cycles between 6 January, 2022 and 20 May, 2022, including provider education, calling families not at bedside, and adjustment to rounding presentations. We visualised change over time relative to interventions with statistical control charts. We conducted a high census days subanalysis. Length of stay and time of transfer from the ICU served as balancing measures.
Results:Mean presence increased from 43 to 83%, demonstrating special cause variation twice. Mean participation increased from 81 to 96%, demonstrating special cause variation once. Mean presence and participation were lower during high census (61 and 93% at project end) but improved with special cause variation. Length of stay and time of transfer remained stable.
Conclusions:Through our interventions, family presence and participation in rounds improved without apparent unintended consequences. Family presence and participation may improve family and staff experience and outcomes; future research is warranted to evaluate this. Development of high level of reliability interventions may further improve family presence and participation, particularly on high census days.
Fetal echocardiographic features associated with bicuspid aortic valve
- Joseph Burns, Madhusudan Ganigara, Jane E. Cerise, Denise A. Hayes
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- 12 May 2023, pp. 50-55
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Background:
Prenatal diagnosis of bicuspid aortic valve is challenging. Bicuspid aortic valve is often associated with aortic dilation.
Methods:Fetuses with postnatally confirmed bicuspid aortic valve were gestational age-matched with normal controls. Complex lesions were excluded. Aortic valve and arch measurements by two blinded investigators were compared.
Results:We identified 27 cases and 27 controls. Estimated fetal weight percentile was lower in cases than controls. Seven cases had one or more significant lesions including perimembranous ventricular septal defects (n = 2), isolated annular hypoplasia (n = 2), and/or arch hypoplasia/coarctation (n = 4). Fetuses with bicuspid aortic valves had significantly smaller median z-scores of the aortic annulus (–1.60 versus –0.53, p < 0.001) and root (–1.10 versus –0.53, p = 0.040), and larger ratios of root to annulus (1.32 versus 1.21, p < 0.001), sinotubular junction to annulus (1.07 versus 0.99, p < 0.001), ascending aorta to annulus (1.29 versus 1.18, p < 0.001), and transverse aorta to annulus (1.04 versus 0.96, p = 0.023). Leaflets were “doming” in 11 cases (41%) and 0 controls (p = 0.010), “thickened” in 10 cases (37%) and 0 controls (p = 0.002). We noted similar findings in the subgroup without significant additional cardiac defects.
Conclusions:The appearance of doming or thickened aortic valve leaflets on fetal echocardiogram is associated with bicuspid aortic valve. Compared to controls, fetuses with bicuspid aortic valve had smaller aortic annulus sizes (possibly related to smaller fetal size) without proportionally smaller aortic measurements, resulting in larger aortic dimension to annulus ratios. Despite inherent challenges of diagnosing bicuspid aortic valve prenatally, these findings may increase suspicion and prompt appropriate postnatal follow-up.
Left ventricle mass index in paediatric intensive care unit acquired hypertension
- Mostafa Mekki, HebatAllah Fadel Algebaly, Hend Aly Sabry, Mohamed Samir, Hanaa Rady
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- 12 May 2023, pp. 56-61
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Background:
Hypertension acquired in paediatric critical patients is a recognised challenge, with variable reported frequency. Pain, agitation, and/or medications such as beta stimulants and corticosteroids are well-known risk factors. Sympathomimetics in septic patients can cause high blood pressure, especially with unobserved haemodynamic monitors. Beyond haemodynamic factors, several endocrinal-metabolic factors – including catecholamines, insulin, renin, angiotensin, the aldosterone system, and sodium consumption – may contribute to the left ventricular growth. It is well known that the sympathetic tone has a trophic effect on the heart muscle.
Method:A prospective cohort study was conducted during the year 2021. The children were divided into two groups: those who were critically ill with paediatric intensive care unit-acquired hypertension (n = 59) and those without paediatric intensive care unit-acquired hypertension (n = 62). We used the American Academy of Pediatrics’ 2017 definition of hypertension to diagnose paediatric intensive care unit-acquired hypertension. Measurement of cardiac output and systemic vascular resistance was performed by cardiometry. Left ventricular myocardial performance and left ventricular mass index were measured by bedside echocardiography at the onset of hypertension diagnosis.
Results:Critically ill children with acquired hypertension had a higher cardiac index (p = 0.0001), systemic vascular resistance index (<0.0001), myocardial performance (0.037), and left ventricular mass index (0.009). The longer duration of stay observed in the hypertension group had no observable effect on mortality (<0.0001).
Conclusion:Both myocardial performance and left ventricle mass index increased in critically ill children with paediatric intensive care unit-acquired hypertension.
Cardiac injury in children with COVID-19
- Joshua M. Herber, Samina S. Bhumbra, Michael W. Johansen, James E. Slaven, Ryan M. Serrano
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- 16 May 2023, pp. 62-66
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Background:
There is little known about the spectrum of cardiac injury in acute COVID-19 infection in children.
Methods:A single-centre, retrospective chart analysis was performed. The protocol was deemed IRB exempt. All patients under the age of 21 years admitted from 20 March, 2020 to 22 June, 2021 for acute symptomatic COVID-19 infection or clinical suspicion of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 were included. Past medical history, lab findings, echocardiogram and electrocardiogram/telemetry findings, and clinical outcomes were reviewed.
Results:Sixty-six patients with MIS-C and 178 with acute COVID-19 were reviewed. Patients with MIS-C had more cardiac testing than those with acute COVID-19. Inflammatory markers were more likely elevated, and function was more likely abnormal on echocardiogram in those with MIS-C with testing performed. Among patients with MIS-C, 17% had evidence of coronary dilation versus 0% in the acute COVID-19 group. One (0.6%) patient with acute COVID-19 had clinically significant electrocardiogram or telemetry findings, and this was in the setting of prior arrhythmias and CHD. Four (6%) patients with MIS-C had clinically significant findings on electrocardiogram or telemetry. Among patients with acute COVID-19, extracorporeal membrane oxygenation support was required in 0.6% of patients with acute COVID-19, and there was a 2.8% mortality. There were no deaths in the setting of MIS-C.
Conclusions:Patients with acute COVID-19 and clinical suspicion of cardiac injury had a lower incidence of abnormal laboratory findings, ventricular dysfunction, or significant arrhythmia than those with MIS-C.
Caregiver and provider attitudes toward family-centred rounding in paediatric acute care cardiology
- Dana B. Gal, Megan Rodts, Brittney K. Hills, Alaina K. Kipps, Danton S. Char, Colleen Pater, Nicolas L. Madsen
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- 18 May 2023, pp. 67-72
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Family-centered rounding has emerged as the gold standard for inpatient paediatrics rounds due to its association with improved family and staff satisfaction and reduction of harmful errors. Little is known about family-centered rounding in subspecialty paediatric settings, including paediatric acute care cardiology.
In this qualitative, single centre study, we conducted semi-structured interviews with providers and caregivers eliciting their attitudes toward family-centered rounding. An a priori recruitment approach was used to optimise diversity in reflected opinions. A brief demographic survey was completed by participants. We completed thematic analysis of transcribed interviews using grounded theory.
In total, 38 interviews representing the views of 48 individuals (11 providers, 37 caregivers) were completed. Three themes emerged: rounds as a moment of mutual accountability, caregivers’ empathy for providers, and providers’ objections to family-centered rounding. Providers’ objections were further categorised into themes of assumptions about caregivers, caregiver choices during rounds, and risk for exacerbation of bias and inequity.
Caregivers and providers in the paediatric acute care cardiology setting echoed some previously described attitudes toward family-centered rounding. Many of the challenges surrounding family-centered rounding might be addressed through access to training for caregivers and providers alike. Hospitals should invest in systems to facilitate family-centered rounding if they choose to implement this model of care as the current state risks erosion of provider–caregiver relationship.
Proinflammatory indicators and the relevance of echocardiography in children with cystic fibrosis
- Ovgu Ozenli Yagci, Ayşe Sulu, Pelin Kosger, Gonca Kilic Yildirim, Hulya Anil, Birsen Ucar, Koray Harmanci
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- 19 May 2023, pp. 73-78
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As the life expectancy improves in cystic fibrosis, cardiac dysfunction is becoming an important risk factor for morbidity and mortality. Here, the association of cardiac dysfunction with proinflammatory markers and neurohormones between cystic fibrosis patients and healthy children was investigated. Echocardiographic measurements of right and left ventricular morphology and functions together with levels of proinflammatory markers and neurohormones (renin, angiotensin-II, and aldosterone) were obtained and analysed in a study group of 21 cystic fibrosis children aged 5–18 years and compared with age- and gender-matched healthy children. It was shown that patients had significantly higher interleukin-6, C-reactive protein, renin and aldosterone levels (p < 0.05), dilated right ventricles, decreased left ventricle sizes, as well as both right and left ventricular dysfunction. These echocardiographic changes correlated with hypoxia, interleukin-1 α, interleukin-6, C-reactive protein, and aldosterone (p < 0.05) levels. The current study revealed that hypoxia, proinflammatory markers, and neurohormones are major determinants of subclinical changes in ventricular morphology and function. While the right ventricle anatomy was affected by cardiac remodeling, the left ventricle changes were induced by right ventricle dilation and hypoxia. A significant but subclinical systolic and diastolic right ventricle dysfunction in our patients was associated with hypoxia and inflammatory markers. Systolic left ventricle function was affected by hypoxia and neurohormones. Echocardiography is a reliable and non-invasive method that is used safely in cystic fibrosis children for screening and detection of cardiac anatomical and functional changes. Extensive studies are needed to determine the time and frequency of screening and treatment suggestions for such changes.
Development of the data registry for the Cardiac Neurodevelopmental Outcome Collaborative
- Anjali Sadhwani, Erica Sood, Andrew H. Van Bergen, Dawn Ilardi, Jacqueline H. Sanz, J. William Gaynor, Michael Seed, Cynthia M. Ortinau, Bradley S. Marino, Thomas A. Miller, Michael Gaies, Adam R. Cassidy, Janet E. Donohue, Amy Ardisana, David Wypij, Caren S. Goldberg
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- 19 May 2023, pp. 79-85
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Children with congenital heart disease (CHD) can face neurodevelopmental, psychological, and behavioural difficulties beginning in infancy and continuing through adulthood. Despite overall improvements in medical care and a growing focus on neurodevelopmental screening and evaluation in recent years, neurodevelopmental disabilities, delays, and deficits remain a concern. The Cardiac Neurodevelopmental Outcome Collaborative was founded in 2016 with the goal of improving neurodevelopmental outcomes for individuals with CHD and pediatric heart disease. This paper describes the establishment of a centralised clinical data registry to standardize data collection across member institutions of the Cardiac Neurodevelopmental Outcome Collaborative. The goal of this registry is to foster collaboration for large, multi-centre research and quality improvement initiatives that will benefit individuals and families with CHD and improve their quality of life. We describe the components of the registry, initial research projects proposed using data from the registry, and lessons learned in the development of the registry.
Effect of comprehensive nursing methods in postoperative ICU of children with CHD
- Shaoyan Lin, Qiong Gao, Xiaoxia He, Zhirong Zhao
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- 25 May 2023, pp. 86-91
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To explore effect of comprehensive nursing in postoperative ICU of children with CHD. The subjects were 50 cases of children with CHD treated in our hospital: 25 cases in the control group: routine nursing, and 25 cases in the observation group: comprehensive nursing intervention. The effective rate of 92.00% in the observation group was significantly higher. The serum-free calcium value (1.07 ± 0.11) mmol/L of the observation group on the first day after surgery was significantly lower, and the observation group’s creatine phosphate, the daily average dosage of creatine phosphate per unit body weight was significantly higher. 96.00% of patients in the observation group were significantly higher in nursing satisfaction. The complication rate of 8.00% in observation group was significantly lower. In order to successfully complete the operation schedule and improve the postoperative recovery effect of children, high requirements are placed on nursing staff. The comprehensive nursing method used in the postoperative ICU of children with CHD can reduce the incidence of postoperative complications and improve nursing satisfaction.
Risk Factors for Adverse Outcomes in Term Infants with CHD and Definitive Necrotising Enterocolitis
- Anna M. Deitch, Katie Moynihan, Robert Przybylski, Kimberlee Gauvreau, Nancy J. Braudis, Bethany Farr, Biren Modi, Kimberly I. Mills, Meena Nathan, Philip T. Levy
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- 25 May 2023, pp. 92-100
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Objectives:
To define the incidence of definitive necrotising enterocolitis in term infants with CHD and identify risk factors for morbidity/mortality.
Methods:We performed a 20-year (2000–2020) single-institution retrospective cohort study of term infants with CHD admitted to the Boston Children’s Hospital cardiac ICU with necrotising enterocolitis (Bell’s stage ≥ II). The primary outcome was a composite of in-hospital mortality and post-necrotising enterocolitis morbidity (need for extracorporeal membrane oxygenation, multisystem organ failure based on the paediatric sequential organ failure assessment score, and/or need for acute gastrointestinal intervention). Predictors included patient characteristics, cardiac diagnosis/interventions, feeding regimen, and severity measures.
Results:Of 3933 term infants with CHD, 2.1% (n = 82) developed necrotising enterocolitis, with 67% diagnosed post-cardiac intervention. Thirty (37%) met criteria for the primary outcome. In-hospital mortality occurred in 14 infants (17%), of which nine (11%) deaths were attributable to necrotising enterocolitis. Independent predictors of the primary outcome included moderate to severe systolic ventricular dysfunction (odds ratio 13.4,confidence intervals 1.13–159) and central line infections pre-necrotising enterocolitis diagnosis (odds ratio 17.7, confidence intervals 3.21–97.0) and mechanical ventilation post-necrotising enterocolitis diagnosis (odds ratio 13.5, confidence intervals 3.34–54.4). Single ventricle, ductal dependency, and feeding related factors were not independently associated with the primary outcome.
Conclusions:The incidence of necrotising enterocolitis was 2.1% in term infants with CHD. Adverse outcomes occurred in greater than 30% of patients. Presence of systolic dysfunction and central line infections prior to diagnosis and need for mechanical ventilation after diagnosis of necrotising enterocolitis can inform risk triage and prognostic counseling for families.
Reduced length of stay after implementation of a clinical pathway following repair of ventricular septal defect
- Tracey L. Ogdon, Rohit S. Loomba, Jamie S. Penk
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- 25 May 2023, pp. 101-104
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Background:
There is variation in care and hospital length of stay following surgical repair of ventricular septal defects. The use of clinical pathways in a variety of paediatric care settings has been shown to reduce practice variability and overall length of stay without increasing the rate of adverse events.
Methods:A clinical pathway was created and used to guide care following surgical repair of ventricular septal defects. A retrospective review was done to compare patients two years prior and three years after the pathway was implemented.
Results:There were 23 pre-pathway patients and 25 pathway patients. Demographic characteristics were similar between groups. Univariate analysis demonstrated a significantly shorter time to initiation of enteral intake in the pathway patients (median time to first enteral intake after cardiac ICU admission was 360 minutes in pre-pathway patients and 180 minutes in pathway patients, p < 0.01). Multivariate regression analyses demonstrated that the pathway use was independently associated with a decrease in time to first enteral intake (–203 minutes), hospital length of stay (–23.1 hours), and cardiac ICU length of stay (–20.5 hours). No adverse events were associated with the use of the pathway, including mortality, reintubation rate, acute kidney injury, increased bleeding from chest tube, or readmissions.
Conclusions:The use of the clinical pathway improved time to initiation of enteral intake and decreased length of hospital stay. Surgery-specific pathways may decrease variability in care while also improving quality metrics.
Left and right ventricular function by echocardiography, tissue doppler imaging, carotid intima media thickness, and asymmetric dimethylarginine levels in female adolescents with vitamin D deficiency
- Eyup Aslan, Ahmet Sert, Muammer Buyukinan, Mustafa Ozgur Pirgon, Huseyin Kurku, Hakan Yılmaz, Dursun Odabas
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- 25 May 2023, pp. 105-112
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Background:
The aim of our study was to assess left and right ventricle systolic and diastolic functions in female adolescents with vitamin D deficiency using conventional echocardiography and pulsed-wave tissue Doppler imaging and to investigate carotid intima media thickness and asymmetric dimethylarginine levels.
Methods:Sixty-six female adolescents were enrolled in this study. The female adolescents were divided into a vitamin D deficiency group (n: 34) and a control group (n: 32). All subjects underwent laboratory blood tests, including asymmetric dimethyl arginine, complete two-dimensional, pulse, and tissue Doppler echocardiography, and measurement of the carotid intima-media thickness.
Results:The vitamin D-deficient female adolescent group had normal left and right ventricle systolic and diastolic functions and normal global systolic and diastolic myocardial performance. In the patients with vitamin D deficiency, the carotid intima-media thickness was higher than that in the controls. In the patients within the vitamin D deficiency group, vitamin D was found to be positively correlated with magnesium and negatively correlated with phosphorus and left atrial dimension.
Conclusions:The results of this study demonstrate that vitamin D deficiency in female adolescence is associated with normal myocardial geometry and function. Although it has been associated with normal levels of asymmetric dimethyl arginine concentration, high measured carotid intima-media thickness may reflect endothelial dysfunction.
Parent communication with care teams and preparation for family meetings in the paediatric cardiac ICU: a qualitative study
- Colette Gramszlo, Hannah Girgis, Douglas Hill, Jennifer K. Walter
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- 25 May 2023, pp. 113-119
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Objective:
The paediatric cardiac ICU presents unique challenges to optimal communication practices, which may impact participation in medical decision-making and long-term psychosocial outcomes for families. This study characterised parent perceptions of (1) team practices that impeded or facilitated communication and (2) preparation for family meetings with interprofessional care teams during extended cardiac ICU admissions.
Methods:A purposive sample of parents of children admitted to the cardiac ICU was selected to participate in interviews about their communication experiences. Data were analysed using a grounded theory approach.
Results:Twenty-three parents of 18 patients participated with an average length of stay of 55 days at the time of interview. Team practices that impeded communication included inaccurate/incomplete communication, inconsistent within team communication/coordination, and feeling overwhelmed by too many team members/questions. Team practices that facilitated communication included valuing parent preferences, provider continuity, explaining jargon, and eliciting questions. Preparation for family meetings included team practices, parental preferences, and experiences when learning about family meetings (including apprehension about meetings). Family meetings were described as valued opportunities to improve communication.
Conclusion:Communication with medical teams represents a modifiable determinant of long-term outcomes for families of children in the cardiac ICU. When parents are included as valued members of their child’s care team, they are more likely to feel a sense of control over their child’s outcomes, even in the face of prognostic uncertainty. Family meetings represent an important opportunity to repair fractures in trust between families and care teams and overcome barriers to communication between parties.
Percutaneous transient occlusion of the transtricuspid flow: a new method to evaluate the right ventricle-dependent coronary circulation in pulmonary atresia with intact ventricular septum
- José Luis Colín Ortiz, Sylvia K. Sánchez González, Bobadilla Aguirre Alfredo, González-Rebeles Guerrero Carlos, Corona Villalobos Carlos Alfonso
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- Published online by Cambridge University Press:
- 26 May 2023, pp. 120-125
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Pulmonary atresia with an intact ventricular septum is characterised by heterogeneity in right ventricle morphology and coronary anatomy. In some cases, the presence of ventriculocoronary connections may promote coronary artery stenosis or interruption, and aortic diastolic pressure may not be sufficient to drive coronary blood flow. This requires a correct evaluation (currently done by angiography) which depends on whether the patient can be offered decompression of the right ventricle. To date, there is no objective method to do so, so we designed a percutaneous, transitory technique with the purpose of occluding the transtricuspid anterograde flow. The manoeuverer was performed in a 25-day-old female with pulmonary atresia with intact ventricular septum, right ventricle at suprasystemic level, and selective coronarography was not conclusive, the anterior descendant with stenosis in its middle third and from this point, thinner with to-fro flow. Occlusion was performed with a balloon catheter. We re-evaluated the coronary flow and the normalised anterior descendant flow. We hope that with this new method, we can give a more accurate diagnosis and determine the cases in which the coronary circulation is truly not right ventricle dependent to offer a greater number of patients biventricular or 1.5 ventricular repairs and thereby improve their quality of life and survival, the ones that turn out to be right ventricular dependant; offer them an early reference for cardiac transplant or in case it is not available to consider univentricular palliation knowing that this probably would not reduce the risk of ischaemia and/or death over time.
Stenting of native right ventricular outflow tract obstructions in symptomatic infants: histological work-up of explanted specimen
- Christoph M. Happel, Harald Bertram, Oliver Kretschmar, Katja Eildermann, Martin O. Schmiady, Matthias Sigler
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- Published online by Cambridge University Press:
- 31 May 2023, pp. 126-130
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Background:
Stenting of stenotic right ventricular outflow tract is a palliative measure for severely impaired small babies with Tetralogy of Fallot or similar pathologies. Little is known about the histopathological fate of the stents in the right ventricular outflow tract.
Methods:Eight samples of surgically removed right ventricular outflow tract stents were histologically analysed according to a predefined protocol.
Results:The most frequent diagnosis was Tetralogy of Fallot in four patients, pulmonary atresia with ventricular septal defect in two patients, double outlet right ventricle with pulmonary obstruction in one patient, and muscular obstruction of the right ventricular outflow tract in one patient with a syndromic disease with hypertrophic cardiomyopathy. Stents mean implantation duration was 444 days ranging from 105 to 1117 days (median 305.5 days). Histology revealed a variable degree of pseudointima formation consisting of fibromuscular cells surrounded by extracellular matrix. Four of the specimen contained adjacent myocardial tissue fragments, which showed regressive changes. Neither myocardium nor pseudointima tissue or tissue parts locally related to stent struts were infiltrated by inflammatory cells.
Conclusions:Histological analysis after explantation of early-in-life implanted right ventricular outflow tract stents revealed predominantly pronounced neo-intimal proliferation with a visible endothelial layer, no signs of inflammation, and no prolapse of muscular tissue through the stent struts. Thus, implantation of stents in early life seems to interfere little with the hosts’ immune system and might help to open up the right ventricular outflow tract by mechanical forces and regressive changes in adjacent muscular tissue.