Projected Future Cancer Risks in Children Treated With Fluoroscopy-Guided Cardiac Catheterization Procedures

International audienceBackground: Cardiac catheterization procedures (CCPs) are increasingly performed in children with congenital heart diseases who have now a long life expectancy and consequently potential long term radiation-induced risks. We evaluated organ equivalent radiation doses and projected Lifetime Attributable Risks (LARs) of cancer incidence from the most frequent procedures in pediatrics: atrial septal defect (ASD) closure, patent ductus arteriosus (PDA) occlusion or pulmonary valvuloplasty. Methods: Organ equivalent doses were individually estimated for 1251 procedures performed in children aged ≤15 years at two reference catheterization centers in France in 2009-2013, based on medical records and exposure scenarios. Gender-specific LARs were projected using the RadRAT software which incorporates extended BEIR VII risk models, various sources of risk projection uncertainties and dose variability. Survival probabilities and baseline cancer risks were those of lifelong non-smokers with no reduced life expectancy due to congenital cardiac diseases.Results: Median equivalent doses were 1-4 mSv (ASD closure), 8-17 mSv (PDA occlusion), and 10 mSv (pulmonary valvuloplasty) to both the lungs and breasts depending on patient age, and ≤10 mSv to other organs. There was a large individual variability, even for a given CCP type and patient age group. Median LARs ranged between 0.3 and 1.4 (ASD closure), 0.6 and 5.0 (PDA occlusion), and 1.0 and 12.0 (pulmonary valvuloplasty) per 1000 procedures, depending on patient gender and age at treatment. These excess risks from CCP radiation exposure would represent 0.4% to 6.0% of children’ total lifetime cancer risk. For the 10% of procedures (all types combined) with highest exposures, LARs reached 4.2 per 1000 [95% Uncertainty Interval (UI): 0.8-13.1] in boys and 22.2 per 1000 (95%UI: 7.4-45.6) in girls. In boys, lung cancer accounted for 70-80% of the projected LARs whereas in girls it accounted for 20-60% and breast cancer for 30-80% of the excess risks, depending on the CCP type and patient age.Conclusion: There was a large individual variability in radiation exposure which may lead to substantial organ equivalent doses and increased cancer risks in some cases. This suggests the need for dose reporting in clinical practice to support recommendations for long term surveillance and prevention strategies

Monitoring of Hemodynamics With Right Heart Catheterization in Children With Pulmonary Arterial Hypertension

Background Right heart catheterization (RHC) is a high‐risk procedure in children with pulmonary arterial hypertension without clear guidelines for the indications and targets of invasive reassessment. Our objectives are to define the aims of repeated RHC and evaluate the correlation between noninvasive criteria and hemodynamic parameters. Methods and Results Clinical and hemodynamic characteristics from 71 incident treatment‐naïve children (median age 6.2 years) with pulmonary arterial hypertension who had a baseline and reevaluation RHC were analyzed. Correlations between noninvasive predictors and hemodynamic parameters were tested. Adverse outcomes were defined as death, lung transplantation, or Potts shunt. At baseline, pulmonary vascular resistance index (hazard ratio [HR] 1.07 per 1 WU·m2 increase [95% CI, 1.02–1.12], P=0.002), stroke volume index (HR 0.95 per 1 L·min−1·m−2 increase [95% CI, 0.91–0.99], P=0.012), pulmonary artery compliance index (HR 0.16 per 1 mL·mm Hg−1·m−2 increase [95% CI, 0.051–0.52], P=0.002), and right atrial pressure (HR, 1.31 per 1 mm Hg increase [95% CI, 1.01–1.71], P=0.043) were associated with adverse outcomes. Pulmonary vascular resistance index, pulmonary artery compliance index, and right atrial pressure were still associated with a worse outcome at second RHC. Noninvasive criteria accurately predicted hemodynamic evolution; however, 70% of the patients who had improved based on noninvasive criteria still presented at least 1 “at risk” hemodynamics at second RHC. Conclusions Pulmonary vascular resistance index, pulmonary artery compliance index, and right atrial pressure are solid predictors of adverse outcomes in pediatric pulmonary arterial hypertension and potential therapeutic targets. Noninvasive criteria accurately predict the evolution of hemodynamic parameters, but insufficiently. Repeated RHC are helpful to identify children with persistent higher risk after treatment introduction

Systematic Electrophysiological Study Prior to Pulmonary Valve Replacement in Tetralogy of Fallot: A Prospective Multicenter Study

International audienceBackground: Ventricular arrhythmias and sudden death are recognized complications in tetralogy of Fallot. Electrophysiological studies (EPS) before pulmonary valve replacement (PVR), the most common reintervention in tetralogy of Fallot, could potentially inform therapy to improve arrhythmic outcomes. Methods: A prospective multicenter study was conducted to systematically assess EPS with programmed ventricular stimulation in patients with tetralogy of Fallot referred for PVR from January 2020 to December 2021. A standardized stimulation protocol was used across all centers. Results: A total of 120 patients were enrolled, mean age 39.2±14.5 years, 53.3% males. Sustained ventricular tachycardia was induced in 27 (22.5%) patients. When identifiable, the critical isthmus most commonly implicated (ie, in 90.0%) was between the ventricular septal defect patch and pulmonary annulus. Factors independently associated with inducible ventricular tachycardia were history of atrial arrhythmia (odds ratio, 8.56 [95% CI, 2.43-34.73]) and pulmonary annulus diameter >26 mm (odds ratio, 5.05 [95% CI, 1.47-21.69]). The EPS led to a substantial change in management in 23 (19.2%) cases: 18 (15.0%) had catheter ablation, 3 (2.5%) surgical cryoablation during PVR, and 9 (7.5%) defibrillator implantation. Repeat EPS 5.1 (4.8-6.2) months after PVR was negative in 8 of 9 (88.9%) patients. No patient experienced a sustained ventricular arrhythmia during 13 (6.1-20.1) months of follow-up. Conclusions: Systematically performing programmed ventricular stimulation in patients with tetralogy of Fallot referred for PVR yields a high rate of inducible ventricular tachycardia and carries the potential to alter management. It remains to be determined whether a standardized treatment approach based on the results of EPS will translate into improved outcomes. Registration: URL: https://clinicaltrials.gov/ct2/show/NCT04205461; Unique identifier: NCT04205461