Pulse Fluoroscopy Radiation Reduction in a Pediatric Cardiac Catheterization Laboratory

ObjectiveTo determine if lower starting pulse fluoroscopy rates lead to lower overall radiation exposure without increasing complication rates or perceived procedure length or difficulty.SettingThe pediatric cardiac catheterization laboratory at University of Michigan Mott Children's Hospital.PatientsPediatric patients with congenital heart disease.Design/InterventionsWe performed a single‐center quality improvement study where the baseline pulse fluoroscopy rate was varied between cases during pediatric cardiac catheterization procedures.Outcome MeasuresIndirect and direct radiation exposure data were collected, and the perceived impact of the fluoroscopy rate and procedural complications was recorded. These outcomes were then compared among the different set pulse fluoroscopy rates.ResultsComparing pulse fluoroscopy rates of 15, 7.5, and 5 frames per second from 61 cases, there was a significant reduction in radiation exposure between 15 and 7.5 frames per second. There was no difference in perceived case difficulty, procedural length, or procedural complications regardless of starting pulse fluoroscopy rate.ConclusionsFor pediatric cardiac catheterizations, a starting pulse fluoroscopy rate of 7.5 frames per second exposes physicians and their patients to significantly less radiation with no impact on procedural difficulty or outcomes. This quality improvement study has resulted in a significant practice change in our pediatric cardiac catheterization laboratory, and 7.5 frames per second is now the default fluoroscopy rate.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111168/1/chd12197.pd

Patient and Procedural Correlates of Fluoroscopy Use During Catheter Ablation in the Pediatric and Congenital Electrophysiology Lab

ObjectiveTo identify factors associated with fluoroscopy use in pediatric and congenital heart disease (CHD) patients.DesignRetrospective cohort.SettingPediatric electrophysiology lab in a single tertiary‐care children's hospital.PatientsThree hundred eighty‐three patients who underwent electrophysiology study and ablation between January 2010 and December 2012.MethodsAblation procedures in which nonfluoroscopic navigation was employed were reviewed. Procedures using ≥10 minutes of fluoroscopy (high‐fluoroscopy time; HF) were compared with those using <10 minutes (low‐fluoroscopy time; LF). Group comparison of characteristics was made in the entire cohort and in CHD and anatomically normal heart subsets.ResultsDuring the study period, 416 ablation procedures were performed involving 471 substrates in 383 patients. Median fluoroscopy time was 6.7 minutes overall and 5.1 minutes with anatomically normal hearts. LF comprised 61% of all ablation and 69% of anatomically normal hearts. LF procedures were associated with anatomically normal hearts (93% vs. 63%; P < .0001). In anatomically normal hearts, HF was associated with accessory pathways (64% vs. 47%; P = .01), posteroseptal substrates (22% vs. 9%; P = .002), and ventricular substrates (12% vs. 1%; P < .0001). All cases of intra‐atrial reentrant tachycardia were HF. HF was associated with trans‐septal puncture (47% vs. 23%; P < .0001) though not when controlling for atrioventricular nodal reentrant tachycardia. LF was associated with cryoablation (56% vs. 17%; P < .0001).ConclusionsIn pediatric and congenital EP, ablation procedures using cryoablation and in patients with anatomically normal hearts are associated with LF. In accessory pathway ablation, HF was not associated with trans‐septal puncture.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111901/1/chd12213.pd

A randomised trial of early palliative care for maternal stress in infants prenatally diagnosed with single-ventricle heart disease

AbstractChildren with single-ventricle disease experience high mortality and complex care. In other life-limiting childhood illnesses, paediatric palliative care may mitigate maternal stress. We hypothesised that early palliative care in the single-ventricle population may have the same benefit for mothers. In this pilot randomised trial of early palliative care, mothers of infants with prenatal single-ventricle diagnoses completed surveys measuring depression, anxiety, coping, and quality of life at a prenatal visit and neonatal discharge. Infants were randomised to receive early palliative care – structured evaluation, psychosocial/spiritual, and communication support before surgery – or standard care. Among 56 eligible mothers, 40 enrolled and completed baseline surveys; 38 neonates were randomised, 18 early palliative care and 20 standard care; and 34 postnatal surveys were completed. Baseline Beck Depression Inventory-II and State-Trait Anxiety Index scores exceeded normal pregnant sample scores (mean 13.76±8.46 versus 7.0±5.0 and 46.34±12.59 versus 29.8±6.35, respectively; p=0.0001); there were no significant differences between study groups. The early palliative care group had a decrease in prenatal to postnatal State-Trait Anxiety Index scores (−7.6 versus 0.3 in standard care, p=0.02), higher postnatal Brief Cope Inventory positive reframing scores (p=0.03), and a positive change in PedsQL Family Impact Module communication and family relationships scores (effect size 0.46 and 0.41, respectively). In conclusion, these data show that mothers of infants with single-ventricle disease experience significant depression and anxiety prenatally. Early palliative care resulted in decreased maternal anxiety, improved maternal positive reframing, and improved communication and family relationships.</jats:p

Fluoroscopy‐guided Umbilical Venous Catheter Placement in Infants with Congenital Heart Disease

ObjectiveThe objective of this study was to (1) describe the technical aspects of fluoroscopy‐guided umbilical venous catheter placement (FGUVCP); and (2) determine the procedural success rate, factors contributing to procedural failure, and risks of the procedure.BackgroundUmbilical venous catheters are advantageous compared with femoral venous access, but can be difficult to place at the bedside.Materials and MethodsThis was a retrospective chart review from a single tertiary care referral institution.ResultsFGUVCP was successful in 138 of 180 patients (76.7%) over a seven‐year period. Patients in whom FGUVCP was successful were younger at the time of procedure compared with patients in whom FGUVCP was unsuccessful (median 18.2 vs. 22.2 hours, P = .03). The optimal age cutoff to predict FGUVCP success was 20 hours with a high positive predictive value (82.4%) but low negative predictive value (32.5%). No other variables were associated with procedural failure, though functional univentricular heart and older gestational age trended toward statistical significance. Median radiation time, contrast exposure, and blood loss were 3.2 minutes, 1 mL, and 1 mL, respectively. A total of 10 complications in 10 patients were associated with FGUVCP.ConclusionsFGUVCP is a safe and highly successful way to obtain central venous access in neonates with congenital heart disease. Older age at the time of procedure is associated with procedural failure, but utilization of an age cutoff may not be clinically useful.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/113170/1/chd12233.pd

The impact of ischemic time on early rejection after pediatric heart transplant

Prolonged graft ischemia may be a risk factor for early rejection postâ HTx, but this has not been well studied in children. Furthermore, factors moderating the association between IT and early rejection have not been investigated. From 2004 to 2012, pediatric HTx recipients (n = 2381) were identified from the UNOS database. A ROC curve determined the optimal IT discriminating patients by the presence of early rejection. Separate univariate analyses identified factors associated with: (i) early (prior to hospital discharge) rejection, and (ii) IT. A multivariable logistic regression assessed independent risk factors for early rejection. We included interaction terms to evaluate whether IT’s independent risk effect on early rejection is moderated via interaction with associated factors found in univariate analysis. Longer IT was associated with an increased risk of early rejection. In multivariable analysis, IT > 3.1 hours was an independent risk factor for early rejection (AOR 1.44, P = .01). No interaction terms between IT and any associated factors were significant. Longer IT is an independent risk for early rejection in pediatric HTx recipients. Better understanding the association between IT and early rejection may identify interventions to mitigate this risk.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/139903/1/petr13034.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/139903/2/petr13034_am.pd

Clinical significance of antiâ HLA antibodies associated with ventricular assist device use in pediatric patients: A United Network for Organ Sharing database analysis

While VAD use in pediatric patients has previously been associated with antiâ HLA antibody production, the clinical significance of these antibodies is unclear. We investigated the clinical impact of antiâ HLA antibodies associated with VAD use in a large cohort of pediatric HTx recipients. From 2004 to 2011, pediatric cardiomyopathy patients postâ HTx (N=1288) with preâ HTx PRA levels were identified from the United Network for Organ Sharing database. PRA levels were compared between VAD patients and those with no history of MCS. Incidence of rejection and overall survival were compared between VAD and nonâ MCS groups after stratification by PRA and age. VAD recipients were more likely to produce antiâ HLA antibodies than nonâ MCS patients (25.5% vs 10.5% had PRA>10%, P10%) had a higher incidence of rejection within 15 months of HTx compared to sensitized nonâ MCS patients (57.1% vs 35.9%, P=.02). There was no intergroup difference in 15â month mortality. Among pediatric cardiomyopathy patients supported with a VAD, the presence of antiâ HLA antibodies prior to HTx is associated with an increased risk of rejection. The mechanism of the association between VADâ associated antibodies and early rejection is unclear and warrants further investigation.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137732/1/petr12938_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137732/2/petr12938.pd

Differential effect of body mass index on pediatric heart transplant outcomes based on diagnosis

The impact of nutritional status on HT x waitlist mortality in children is unknown, and there are conflicting data regarding the role of nutrition in post‐ HT x survival. This study examined the influence of nutrition on waitlist and post‐ HT x outcomes in children. Children 2–18 yr listed for HT x from 1997 to 2011 were identified from the OPTN database and stratified by BMI percentile. Multivariable logistic regression evaluated the influence of BMI on waitlist mortality. Cox proportional hazard regression assessed the impact of BMI on post‐ HT x mortality. When all 2712 patients were analyzed, BMI did not impact waitlist, one‐, or five‐yr mortality. However, when stratified by diagnosis, BMI  > 95% ( AOR 1.96; 95% CI 1.24, 3.09) and BMI   95% and BMI  < 1% are independent risk factors for waitlist mortality in patients with CM, but not CHD . This suggests differing risk factors based on disease etiology, and an individualized approach to risk assessment based on diagnosis may be warranted.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/108679/1/petr12352.pd

Survey of the Effective Exercise Habits of the Formerly Obese

This survey indicates that patients who have undergone weight loss surgery can achieve excellent weight loss and sustain a normal BMI with regular exercise habits that are distinct from those of younger individuals who are not obese

Rate of increase in serum lactate level risk-stratifies infants after surgery for congenital heart disease

ObjectiveIncreased blood lactate levels reflect tissue oxygen debt and might be indicative of low cardiac output. We hypothesized that the rate of increase in serum lactate would be an ideal marker to discriminate between infants at high and low risk of a poor outcome after surgical repair of congenital heart disease using cardiopulmonary bypass.MethodsIn the present prospective, observational study in a pediatric cardiac intensive care unit, infants (aged <12 months) undergoing cardiac surgery had serial whole blood lactate levels measured with every arterial blood gas drawn for the first 24 postoperative hours. The composite poor outcome included death, the need for extracorporeal support, and dialysis.ResultsThe lactate levels were measured in 231 infants; 19 infants (8.2%) had a poor outcome. A lactate increase rate of 0.6 mmol/L/h had very good discriminatory ability (area under the curve [AUC], 0.89) with a sensitivity of 90%, specificity of 84%, positive predictive value (PPV) of 34%, and negative predictive value (NPV) of 99%. Similar results were obtained for subgroups stratified by 1- or 2-ventricle heart disease and risk adjustment for congenital heart surgery (RACHS-1) score. In neonates (age <30 days) with single-ventricle physiology (n = 43, poor outcome = 8), a lactate increase of 0.6 mmol/L/h had near perfect discriminatory ability (AUC 0.99) with a sensitivity of 100%, specificity of 51%, PPV of 32%, and NPV of 100%. In 2-ventricle neonates (n = 43, poor outcome = 5), a lactate increase of 0.6 mmol/L/h also had near perfect discriminatory ability (AUC, 0.99), with a sensitivity of 100%, specificity of 90%, PPV of 56%, and NPV of 100%.ConclusionsThe postoperative lactate increase rate allows discrimination between infants at high and low risk of morbidity and mortality after congenital heart disease surgery, and the lactate level can be followed serially for the treatment response