Risk Factors for Major Early Adverse Events Related to Cardiac Catheterization in Children and Young Adults With Pulmonary Hypertension: An Analysis of Data From the IMPACT (Improving Adult and Congenital Treatment) Registry.

BACKGROUND: Cardiac catheterization is the gold standard for assessment and follow-up of patients with pulmonary hypertension (PH). To date, there are limited data about the factors that influence the risk of catastrophic adverse events after catheterization in this population. METHODS AND RESULTS: A retrospective multicenter cohort study was performed to measure risk of catastrophic adverse outcomes after catheterization in children and young adults with PH and identify risk factors for these outcomes. All catheterizations in children and young adults, aged 0 to 21 years, with PH at hospitals submitting data to the IMPACT (Improving Adult and Congenital Treatment) registry between January 1, 2011, and December 31, 2015, were studied. Using mixed-effects multivariable regression, we assessed the association between prespecified subject-, procedure-, and center-level covariates and the risk of death, cardiac arrest, or mechanical circulatory support during or after cardiac catheterization. A total of 8111 procedures performed in 7729 subjects at 77 centers were studied. The observed risk of the composite outcome was 1.4%, and the risk of death before discharge was 5.2%. Catheterization in prematurely born neonates and nonpremature infants was associated with increased risk of catastrophic adverse event, as was precatheterization treatment with inotropes and lower systemic arterial saturation. Secondary analyses demonstrated the following: (1) increasing volumes of catheterization in patients with PH were associated with reduced risk of composite outcome (odds ratio, 0.8 per 10 procedures; CONCLUSIONS: Young patients with PH are a high-risk population for diagnostic and interventional cardiac catheterization. Hospital experience with PH is associated with reduced risk, independent of total catheterization case volume

Radiation-free CMR diagnostic heart catheterization in children.

BACKGROUND: Children with heart disease may require repeated X-Ray cardiac catheterization procedures, are more radiosensitive, and more likely to survive to experience oncologic risks of medical radiation. Cardiovascular magnetic resonance (CMR) is radiation-free and offers information about structure, function, and perfusion but not hemodynamics. We intend to perform complete radiation-free diagnostic right heart catheterization entirely using CMR fluoroscopy guidance in an unselected cohort of pediatric patients; we report the feasibility and safety. METHODS: We performed 50 CMR fluoroscopy guided comprehensive transfemoral right heart catheterizations in 39 pediatric (12.7 ± 4.7 years) subjects referred for clinically indicated cardiac catheterization. CMR guided catheterizations were assessed by completion (success/failure), procedure time, and safety events (catheterization, anesthesia). Pre and post CMR body temperature was recorded. Concurrent invasive hemodynamic and diagnostic CMR data were collected. RESULTS: During a twenty-two month period (3/2015 - 12/2016), enrolled subjects had the following clinical indications: post-heart transplant 33%, shunt 28%, pulmonary hypertension 18%, cardiomyopathy 15%, valvular heart disease 3%, and other 3%. Radiation-free CMR guided right heart catheterization attempts were all successful using passive catheters. In two subjects with septal defects, right and left heart catheterization were performed. There were no complications. One subject had six such procedures. Most subjects (51%) had undergone multiple (5.5 ± 5) previous X-Ray cardiac catheterizations. Retained thoracic surgical or transcatheter implants (36%) did not preclude successful CMR fluoroscopy heart catheterization. During the procedure, two subjects were receiving vasopressor infusions at baseline because of poor cardiac function, and in ten procedures, multiple hemodynamic conditions were tested. CONCLUSIONS: Comprehensive CMR fluoroscopy guided right heart catheterization was feasible and safe in this small cohort of pediatric subjects. This includes subjects with previous metallic implants, those requiring continuous vasopressor medication infusions, and those requiring pharmacologic provocation. Children requiring multiple, serial X-Ray cardiac catheterizations may benefit most from radiation sparing. This is a step toward wholly CMR guided diagnostic (right and left heart) cardiac catheterization and future CMR guided cardiac intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT02739087 registered February 17, 2016

Language of Lullabies: The Russification and De-Russification of the Baltic States

This article argues that the laws for promotion of the national languages are a legitimate means for the Baltic states to establish their cultural independence from Russia and the former Soviet Union

Outcomes of Patients with Pulmonary Atresia and Major Aortopulmonary Collaterals Without Intervention in Infancy.

INTRODUCTION: Treatment of pulmonary atresia with major aortopulmonary collaterals (PA MAPCA’s) remains a challenge. Despite variations in surgical technique, contemporary strategies all include initial intervention in the first year of life. However, a subset of patients presents later in life, and contemporary outcomes of this group have not been reported previously. METHODS: We performed a retrospective case series of consecutive cases of PA MAPCA’s who did not undergo surgery before the age of 1 year from 1/2001 and 2/2016. We describe their presenting characteristics, operative and transcatheter interventions, and outcomes. RESULTS: A total of 8 cases were identified from 76 children with PA MAPCA’s treated over the study period. Median age at presentation was 5.9 years. 75% had confluent pulmonary arteries with a median Nakata index of 113 mm(2)/m(2). Operative intervention was performed in 5/6 cases. Two are awaiting intervention. The combination of operative and transcatheter interventions allowed for ventricular septal defect closure in 60% of cases, all of whom had sub-systemic right ventricular pressures. CONCLUSION: Operative intervention is possible in some older cases with PA and MAPCA’s. Though multiple operations and transcatheter therapies are necessary some can achieve operative correction of serial circulation with tolerable physiology. Subjects with ventricular hypoplasia and those without confluent pulmonary arteries are more challenging

Measured Oxygen Consumption During Pediatric Cardiac Catheterization is More Accurate than Assumed Oxygen Consumption

When calculating cardiac index (C.I.) by the Fick method, oxygen consumption (VO) is often unknown, so assumed values are typically used. This practice introduces a known source of inaccuracy into the calculation. Using a measured VO (mVO) from the CARESCAPE E-sCAiOVX module provides an alternative that may improve accuracy of C.I. calculations. Our aim is to validate this measurement in a general pediatric catheterization population and compare its accuracy with assumed VO (aVO). mVO was recorded for all patients undergoing cardiac catheterization with general anesthesia and controlled ventilation during the study period. mVO was compared to the reference VO (refVO) determined by the reverse Fick method using cardiac MRI (cMRI) or thermodilution (TD) as a reference standard for measurement of C.I. when available. 193 VO measurements were obtained, including 71 with a corresponding cMRI or TD measure of cardiac index for validation. mVO demonstrated satisfactory concordance and correlation with the TD- or cMRI-derived refVO (ρ = 0.73, r = 0.63) with a mean bias of - 3.2% (SD ± 17.3%). Assumed VO demonstrated much weaker concordance and correlation with refVO (ρ = 0.28, r = 0.31) with a mean bias of + 27.5% (SD ± 30.0%). Subgroup analysis of patients \u3c 36 months of age demonstrated that error in mVO was not significantly different from that observed in older patients. Many previously reported prediction models for assuming VO performed poorly in this younger age range. Measured oxygen consumption using the E-sCAiOVX module is significantly more accurate than assumed VO when compared to TD- or cMRI-derived VO in a pediatric catheterization lab

Severe tricuspid valve stenosis secondary to pacemaker leads presenting as ascites and liver dysfunction: A complex problem requiring a multidisciplinary therapeutic approach

Tricuspid stenosis secondary to ventricular pacemaker leads is uncommon. We present a unique case of iatrogenic tricuspid stenosis secondary to fusion of the valve leaflets to transvenous implanted pacing leads. This occurred in an adult with childhood repaired Tetralogy of Fallot and high grade surgical heart block following multiple pacemaker procedures. The case was complicated by superior vena cava (SVC) and innominate vein stenosis secondary to implanted pacing leads, severe tricuspid valve (TV) stenosis, perforation of the heart by one of the implanted transvenous ventricular pacing leads, prolapse of the transvenous atrial pacing lead into the right ventricle, and unusual coronary sinus anatomy. We describe a multidisciplinary approach to management. © Springer Science+Business Media, LLC 2008

A Proactive Diabetes Panel Management Approach: Can It Work and How Does It Work in a Health Care Delivery System?

Background/Aims: Guidelines have been established for the care of type 2 diabetes (T2DM) patients. However, ~50% of adult patients receive the recommended care. Factors contributing to the low rate may include shortage of primary care physicians (PCP) and lack of knowledge and compliance at the patient level. To close this care gap, Kaiser Permanente Southern California (KPSC) initiated proactive panel management (PPM). PPM is a standardized and centralized process in which a health care team supports physicians by proactively identifying and evaluating patients with key and actionable care gaps, and providing patient-specific recommendations to help close the gaps. Patients with glycated HbA1c ≥ 9% were eligible. The purpose of this study was to evaluate clinical comparative effectiveness of PPM in achieving HbA1c control (defined as glycated HbA1c \u3c 9%). Methods: Data for 10,581 adult T2DM patients who had glycated HbA1c ≥ 9% in 2011 (baseline) but had not received PPM in that year were extracted from electronic medical records. Logistic regression was used to evaluate effectiveness of PPM in 2012 (follow-up) on HbA1c control. Results: Among the 10,581 patients, 6,728 (63.6%) received PPM during 2012. At baseline, receivers were more likely to be 45–64 years of age, female, and had more years of education than nonreceivers. The two groups were similar in race/ethnicity and household income. During follow-up, the PPM group had a greater reduction in HbA1c (mean [standard deviation]: -2.0 [2.2] vs. -1.6 [2.1], P\u3c0.0001) and a higher percentage of patients achieved HbA1c control (63% [4,232 of 6,728] vs. 54% [2,079 of 3,853], P\u3c0.0001) than the non-PPM group. The differences were not explained by social demographics, baseline service utilization and HbA1c. More patients in the PPM group had a PCP visit and used an antidiabetic medication than the non-PPM group during 2012; these two factors explained the majority of the association between PPM and HbA1c control. PPM was most effective for patients with higher educational attainment, no PCP visit or use of any antidiabetic medication at baseline. Discussion: PPM using patient-level information in electronic medical records and technology within a prepaid health care delivery system can effectively increase diabetic control for high-risk T2DM patients

A Proactive Diabetes Panel Management Approach: Can It Work and How Does It Work in a Health Care Delivery System?

Background/Aims: Guidelines have been established for the care of type 2 diabetes (T2DM) patients. However, ~50% of adult patients receive the recommended care. Factors contributing to the low rate may include shortage of primary care physicians (PCP) and lack of knowledge and compliance at the patient level. To close this care gap, Kaiser Permanente Southern California (KPSC) initiated proactive panel management (PPM). PPM is a standardized and centralized process in which a health care team supports physicians by proactively identifying and evaluating patients with key and actionable care gaps, and providing patient-specific recommendations to help close the gaps. Patients with glycated HbA1c ≥ 9% were eligible. The purpose of this study was to evaluate clinical comparative effectiveness of PPM in achieving HbA1c control (defined as glycated HbA1c \u3c 9%). Methods: Data for 10,581 adult T2DM patients who had glycated HbA1c ≥ 9% in 2011 (baseline) but had not received PPM in that year were extracted from electronic medical records. Logistic regression was used to evaluate effectiveness of PPM in 2012 (follow-up) on HbA1c control. Results: Among the 10,581 patients, 6,728 (63.6%) received PPM during 2012. At baseline, receivers were more likely to be 45–64 years of age, female, and had more years of education than nonreceivers. The two groups were similar in race/ethnicity and household income. During follow-up, the PPM group had a greater reduction in HbA1c (mean [standard deviation]: -2.0 [2.2] vs. -1.6 [2.1], P\u3c0.0001) and a higher percentage of patients achieved HbA1c control (63% [4,232 of 6,728] vs. 54% [2,079 of 3,853], P\u3c0.0001) than the non-PPM group. The differences were not explained by social demographics, baseline service utilization and HbA1c. More patients in the PPM group had a PCP visit and used an antidiabetic medication than the non-PPM group during 2012; these two factors explained the majority of the association between PPM and HbA1c control. PPM was most effective for patients with higher educational attainment, no PCP visit or use of any antidiabetic medication at baseline. Discussion: PPM using patient-level information in electronic medical records and technology within a prepaid health care delivery system can effectively increase diabetic control for high-risk T2DM patients